First Name: *

Last Name: *

Phone Number *

Address: Remember you MUST be a Philadelphia Resident to receive the COVID-19 Vaccine in Phase 1B *

Please enter your Zip Code

Are you over the age of 18? *

Age *

Date of Birth MM/DD/YYYY *

Gender *

Do you have Health Insurance? There will be no out of pocket cost to receive the COVID-19 vaccination. *

If you answered "yes" above, please list: Health Insurance Company, Address, Policy Number, and Telephone Number

Do you have a Primary Care Physician or Provider? *

If you answered "yes" above, please list: Name and telephone number of primary care physician (PCP).

Race/Ethnicity (check all that apply) *

Do you require an interpreter? If YES, please indicate the language.

Have you tested positive for COVID-19? *

If you answered "yes" above, please provide the date of your positive COVID-19 Diagnosis.

What is your occupation? Please check one

Do you have any health conditions? (check all that apply) *

Do you have allergies to injectable medications or vaccines? *

If you answered yes, what reactions did you have to the injectable medications or vaccines?

Notice of Information Practices - It Takes Philly, Inc. (ITP) & Black Doctors COVID19 Consortium (BDCC) and Stanford Pediatric Surgery, LLC and its employees and volunteers collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voicemails, forms, and from the submission of applications that are either required by law or necessary to process applications or other requests for assistance through our organization. Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voicemails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence. We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that are considered patient confidential, restricted by law, or specifically restricted by a patient/client. Information is only used as is reasonably necessary to process your COVID19 Vaccine or to provide you with health or counseling services which may require communication between ITP & BDCC and health care providers, medical product or service providers, pharmacies, insurance companies, and other providers necessary to verify your medical information is accurate and determine the type of medical supplies or health care services you need. This is including, but not limited to, or to obtain or purchase any type of medical supplies, devices, medications, or insurance. If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law. We do not use cookies on our website to collect data from our site visitors. We do not collect information about site visitors except for one hit counter on the main index page www.blackdoctorsconsortium.com that simply records the number of visitors and no other data. We do use some affiliate programs that may or may not capture traffic dates through our site. To avoid potential data capture that you visited a diabetes website simply do not click on any of our outside affiliate links. *

DISCLAIMER: You agree and affirm that you will not hold It Takes Philly, Inc., Black Doctors COVID19 Consortium or Stanford Pediatric Surgery, LLC liable for any issues associated with your vaccine and/or subsequent treatment or care you receive from another facility or ambulance. *

DISCLAIMER: I hereby consent to the use of my name and likeness, including my performance, voice, and image in any form, as incorporated in the Black Doctors COVID19 Consortium (BDCC) for the purpose of advertising and promotion in any media, throughout the world in perpetuity, including but not limited to social media or on the world wide web. If my likeness is used in any manner, I hereby irrevocably consent to BDCC’s use as set forth above. I agree that BDCC shall own all right, title and interest to the Entry (including all content and all rights embodied therein) and that it may exploit, edit, modify, and distribute the Entry, without limitation, and without compensation, further permission or notification to me. I hereby waive any inspection or approval of use. I also waive and release BDCC from any claims based upon invasion of privacy, right of publicity, defamation, false endorsement, or claim of visual or audio alteration or faulty mechanical reproduction.” The reason for this term is to allow BDCC to use any content obtained at our sites in our marketing and promotions materials and to also allow the media to use any footage obtained. *