COVID-19 Vaccine Appointment Form
Pfizer Vaccine is for Anyone Age 16 and over
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Date of Birth
What is your gender assigned to birth?
What is your current gender?
What is your ethnicity?
American Indian or Alaskan Native
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Are you currently employed?
Do you work form home?
What is the possible nearest date for you to work from main office?
Zip code for your main office
How often do you go in person to your main workplace currently?
One day in a week
2-4 days in a week
5 or more days in a week
Does your main workplace have social distancing measures in place?
Do you and other people in your main workplace use personal protection equipment such as masks?
How do you get to work? (select all that apply)
By own car
Public transportation (train, bus, etc)
Walk / bike
In general, how many people do you physically interact with in your main workplace?
More than 50 people
How many people live in your household? (including you)
I live alone
More than 4 people
Is there anyone in your household who is older than 64?
Is there anyone in your household who attend school or child care?
I hereby certify that the above information is true and correct to the best of my knowledge
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