Bracken County Health Department Pediatric COVID-19 Vaccine Registration Form
PEDIATRIC PATIENTS ONLY
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Age
*
Gender
*
Female
Male
Hispanic/Latino
*
Please Select
Yes
No
Race (Check all that apply)
*
White
Black
American Indian/Alaskan
Hawaiian/Pacific Islander
Asian
Multiracial
Phone Number
*
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Do you have any chronic health condition? (Type NONE if you do not have any health conditions)
*
Please indicate all health issues that are considered within the risk group
Which COVID Vaccine do you want?
Please Select
Pfizer age 6mths to 4 yrs
Pediatric Pfizer Age 5-11
Pfizer Age 12 and up
Moderna 6mth to 5 years
Moderna 6yrs to 11 years
Moderna age 12 yrs and up
Please select the type of vaccine you want.
Have you been diagnosed with COVID-19 in the last 90 days?
*
Please Select
Yes
No
Have you received any vaccine in the past 14 days?
*
Please Select
Yes
No
Appointment
*
Register
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