EmailMeForm
COVID-19 Vaccine Sign-up
Name
*
First
Last
Date of Birth
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MM
/
DD
/
YYYY
Age
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
County
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Phone
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Have you been diagnosed by a doctor with any of the following health conditions? Check all that apply.
Cancer
Chronic kidney disease
COPD (chronic obstructive pulmonary disease)
Down Syndrome
Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
Immunocompromised state (weakened immune system) from solid organ transplant
Obesity (body mass index [BMI] of 30 kg/m2 or higher but less than 40 kg/m2)
Severe Obesity (body mass index [BMI] equal to or greater than 40 kg/m2)
Pregnancy
Sickle cell disease
Type 2 diabetes mellitus
