NORTH Pacific County COVID-19 Vaccine Waitlist
Please only complete this form if you live or work in NORTH Pacific County AND you are currently eligible for the vaccine (currently that only includes those over 65, certain folks over 50 who live in multigenerational households, and people who work in a healthcare setting). All others will be deleted.
Completing this form puts you on the waitlist. Once we have vaccine and your number comes up, a provider in Pacific County will call you to schedule an appointment. Due to lack of vaccine supply, it may be several weeks before you receive a call. To find out what number you are on the waitlist, you can email us at
info1@pacificcountyhealth.com
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Last Name
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Your answer
First Name
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Your answer
Age
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Your answer
Date of birth
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MM
/
DD
/
YYYY
Address
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Your answer
City
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Your answer
Zip code
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Your answer
Phone
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Your answer
Email address
Your answer
Ethnicity
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Hispanic
Non Hispanic
Prefer to not answer
Race
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White
African American
American Indian
Asian
Hawaiian/Pacific Islander
Other
Prefer not to answer
Do you have a known history of a severe allergic reaction (e.g. anaphylaxis) to this vaccine or any components of the vaccine such as lipids, potassium chloride, monobasic potassium phosphate, sodium chloride, dibasic sodium phosphate dihydrate, and sucrose?
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Yes
No
In the past two weeks, have you tested positive for COVID-19?
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Yes
No
In the past 2 weeks, have you had exposure to a person who tested positive for COVID-19 at a distance of 6 feet or less for more than 15 minutes without personal protective equipment, such as masks?
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Yes
No
Have you had new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle/body aches, headache, new loss of taste/smell, sore throat, nausea, vomiting or diarrhea?
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Yes
No
In the past 90 days have you received passive antibody therapy as part of COVID-19 treatment?
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Yes
No
Are you pregnant or breastfeeding or do you plan to become pregnant?
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Yes
No
Are you immune compromised or on a medicine that affects your immune system?
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Yes
No
Do you have a bleeding disorder or are you on a blood thinner?
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Yes
No
Do you have a history of severe allergic reaction (anaphylaxis) to another vaccine or injectable medication?
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Yes
No
Have you received any other vaccinations in the past two weeks?
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Yes
No
Emergency contact name
Your answer
Emergency contact phone number
Your answer
What type of insurance do you have?
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Medicaid
Medicare
Private insurance
I don't have insurance
If you have private insurance, what is the name of your insurance company?
Your answer
If you have private insurance, what is your policy number?
Your answer
Do you live in a multigenerational household? This means you live with and care for a younger relative who is not your own child OR you are not able to live independently and you have in-home care.
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Yes
No
Do you work in a healthcare setting?
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Yes
No
Do you live or work in Pacific County?
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Yes
No
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