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Vaccine Registration Consent -Form Fill

Q1

Are you a healthcare worker? (Category/Phase 1A)
Q2

Are you 65 or over? (Category/Phase 1B)
Q3

Are you 16 or older with at least one of the following chronic conditions?
Q4

Do you have an allergic reaction to the COVID-19 Vaccine?
Q5

Do you have an allergic reaction to any vaccine?
Q6

Do you feel sick today?
Q7

Have you experienced any of the following symptoms within 10 days?
Q8

Have you had a positive COVID-19 test within 14 days?
Q9

Did you receive a previous dose of any COVID-19 vaccine?
Q10

Do you have a bleeding disorder or are you on a blood thinner/blood-thinning medication?
Q11

Are you immunocompromised or on a medicine that affects your immune system?
Q12

First Name

Name
Q13

Last Name

Name
Q14

Confirmation Email

Email
Q15

Phone Number
Q16

Date of Birth
Q18

Age
Q19

Street Address

Address
Q20

Street Address Line 2

Address
Q21

City

Address
Q22

State

Address
Q23

Postal / Zip Code

Address
Q24

County
Q25

Race
Q26

Ethnicity
Q27

Gender
Q28

Please select the dose of the vaccine you are scheduling.
Q29

Consent
Q30

Signature