COVID-19 Vaccination Waitlist
Tell us about who you are so we can contact you when the vaccine is available.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
COVID-19 Phase Questions
*
I am age 65 or older
Are you a healthcare employee or professional (Do you work in one of the following: hospital, long-term care facilities, outpatient clinic, home health care, pharmacy, emergency medical service, or public health)?
Are you a resident of a long-term care facility (skilled nursing facility, assisted living facility, or other residential care)?
Are you an essential worker (Do you work in education, food & agriculture, utilities, police, firefighter, corrections officer, or transportation)?
Do you have a high-risk medical condition (i.e. cancer, chronic kidney disease, COPD, diabetes, heart conditions such as heart failure, coronary artery disease, or cardiomyopathies, obesity (BMI > 30 kg/m2), pregnancy, sickle cell disease, and/or smoking)
None of the above
Are you willing to be on a standby list? (i.e. able to come to the office within 1 hour if an appointment opens up)
*
Yes
No
Submit
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