COVID Vaccine List
Please share your information here to be added to the vaccine registry for Rooks County.
Your Name *
First Name (of person to be vaccinated) *
Last Name (of person to be vaccinated) *
Date of Birth (of person to be vaccinated) *
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DD
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County of Residence (of person to be vaccinated) *
Mailing Address (of person to be vaccinated) *
City (of person to be vaccinated) *
State (of person to be vaccinated) *
Zip Code (of person to be vaccinated) *
Primary Care Provider (of person to be vaccinated) *
Best Contact Number (of person to be vaccinated) *
Any vaccine preference? *
Does the person to be vaccinated live in a nursing home or assisted living setting (institutional setting)? *
Severe risk: does the person to be vaccinated have any of the following conditions: cancer, chronic kidney disease, COPD, Down Syndrome, heart disease, history of solid organ transplant, type 2 diabetes, sickle cell disease or pregnancy? *
Other medical risk: does the person to be vaccinated have any of the following conditions: asthma, stroke, cystic fibrosis, immunocompromised state, neurologic conditions (like dementia), liver disease, pulmonary fibrosis, thalassemia, type 1 diabetes or obesity? *
Any additional information you would like to provide?
Has the person to be vaccinated received monoclonal antibody treatment (Bamlanivimab or Regeneron) for COVID? *
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