COVID-19 Vaccine Waitlist Request

The following information is required to be registered to our waitlist. You must meet current state/county eligibility guidelines to be added to our waitlist. Submissions of this request does not guarantee vaccination. We will reach out to you when a dose becomes available based on the prioritized groups, we prioritize all eligible groups first and then move to other groups. You can only enter our waitlist once.

Which of these requirements do you meet?

Please select all that apply:

Are you a current Men's Health Foundation patient?

Yes

Last Name

First Name

Mother's Maiden Name

Date of Birth

Phone Number

Race/Ethnicity

Age

Gender

Female

Male

Other

Address

City

State

Zip Code

County

Email Address

Occupation

Health Questions

For vaccine recipients: The following questions will help us determine if there is any

Have you previously received a COVID-19 vaccine?

Yes

I Don't Know

Is this your First or Second COVID-19 vaccination?

First

Second

Do you have a fever?

Yes

I Don't Know

Are you feeling sick?

Yes

I Don't Know

Have you received any vaccine in the past 2 Weeks?

Yes

I Don't Know

Have you had an allergic reaction to a vaccine?

(e.g. anaphylaxis) o another vaccine (not including Pfizer-BioNTech or Moderna Vaccine) or any other injectable medication

Yes

I Don't Know

Do you have a weakened immune system?

caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies

Yes

I Don't Know

Do you have any of the following ?

Have you received passive antibody therapy?

(monoclonal antibodies or convalescent serum) as treatment for COVID-19

Yes

I Don't Know

Have you had a positive test for COVID-19?

Yes

I Don't Know

Health Insurance

Do you currently have Health Insurance coverage?

Yes

Document Upload

Please Upload the Following Documents: 1) State or Federally Issued Identification 2) Proof of Healthcare Employment (e.g. Paystub, State issued License/Certificate, Letter from Employer) 3) Images of Front and Back of Insurance Card

Drop your files here

Consent to Vaccination

In checking this box, I give permission to be vaccinated and understand that my vaccination will be entered into my local California Immunization Registry (CAIR2, HealthFutures or SIDR). Further, I agree that: (1) The information provided is correct (2) I have read the EUA Fact Sheet provided (3) I understand the risks and benefits of getting the vaccine(s) and consent for me and my family to be vaccinated (4) Any questions I had about the vaccine(s) have been answered;

Appointment

Desired Appointment Location

8280 Santa Monica Blvd. Los Angeles CA 90046

2700 W Manchester Blvd Inglewood CA 90305

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