Palo Pinto County COVID-19 Vaccine Registration Form
Please fill out this form to the best of your ability.
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Street Addresses *
City *
Zip Code *
Date of Birth *
Phone Number *
Please provide your ten digit number with no dashes, spaces, or parentheses.
Are you 50 years of age or older? *
Are you 16 years of age and older with at least one of the following chronic medical conditions: cancer, chronic kidney disease, COPD, heart conditions (heart failure, coronary artery disease or cardiomyopathies), solid organ transplantation, obesity, pregnancy, sickle cell disease, type 2 diabetes? *
Are you a current health care provider / first responder? *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy