COVID-19 Vaccine Assessment Form

A new submission needs to be completed for each individual family member. Please make sure to fill out the entire form until you get to the last page that says Thank You! You should also receive an email confirmation from Jotform.
Name *

First Name Last Name
Birthdate *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number *

Area Code Phone Number
Email *
example@example.com
Are you one of the following *

Healthcare Worker Age 70 and older Frontline Essential Worker (first responder, education, grocery, meat processing, manufacturing, postal service) Age 65 - 69 Age 16-64 with high risk medical condition Other Essential Workers (food service, public health workers and media among other occupations)
Employer
County

Garland Saline Sebastian Van Buren Miller Hot Spring Pope Crawford Pulaski
Type of Insurance

Medicare Medicaid Private/Commercial Uninsured TriCare or VA Insurance
Please specify any underlying medical conditions that apply to you

Diabetes Heart Failure COPD Asthma Kidney Disease Liver Disease High Blood Pressure High Cholesterol Autoimmune Disorders Cancer HIV Hepatitis C
Should be Empty:

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