Covid-19 Vaccination Clinic
First Name
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Middle Initial
Last Name
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Date of Birth
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SSN
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Gender
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Phone Number
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Area code & phone number
Phone Type
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Email Address
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Street Address
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Add Community address if completing for a resident
Street Address 2
City
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Add Community Address if completing for a resident
State Code
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Zip Code
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County
County of Residence
Race
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Select all that apply
Ethnicity
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Insurance Type
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Insurance is not required to receive the vaccine, however if you have insurance, it is collected for billing purposes. There is no out of pocket cost to you for the vaccine regardless if you have insurance or not.
COVID-19 Vaccine Dose Requested
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Chronic Health Conditions
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Select all that apply
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