Your Name *

First Name (of person to be vaccinated) *

Last Name (of person to be vaccinated) *

Date of Birth (of person to be vaccinated) *

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? *