Palo Pinto County COVID-19 Vaccine Registration Form
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First Name *
Last Name *
Street Addresses *
City *
Zip Code *
Date of Birth *
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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? *
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