Vaccine Shark Intake Form
*Español* https://forms.gle/JzNZ9w52pP42Y5o87
*عربى* https://bit.ly/3dUtnzP

*Who are you?*
Hi! We're a group of 9 volunteers who got frustrated with the vaccine process in MO and want to help. We're happy you're here! We will do our best to meet special requests, but they may take us extra time. We've helped around 800 people find appointments so far and we're not done!

*Is it my turn yet?*
YES! Everyone 16+ in MO is "officially" eligible starting Friday 4/9. If you're really nervous about the rules let us know in the scheduling comments and we'll be sure to book your appointment on/after 4/9!

*2nd Dose Appointments*
We can only accept forms for 2nd doses if you're due in the next 7 days! No wait list here! We can book you a dose closer to home if you travelled for your first. But you have to promise you'll call the pharmacy where you got your first dose so they know you aren't coming to your 2nd dose appointment!

*Timing*
Please don't fill out this form if you can't make it to a vaccine appointment in the next week. Bookmark it and fill it in later :)

*Communications*
We will contact the number and email listed on the form when your appointment is booked or if we have questions about your form. If you are filling this form out on behalf of someone else, please be sure they are aware that they may hear from us (or use your contact number/email)!

Please complete this form so that we have accurate information to book your vaccine appointment! We promise to never share or sell your info outside our small group of volunteers.

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I understand that the Sharks will get me an appointment in the next day or two for sometime in the next week! *
If we find you an appointment that meets your request from this form it will be your responsibility to cancel the appointment if you can't go to it. If we mess up we'll cancel the appointment for you!
Region *
First Name *
The name you use when you go to the doctor
Last Name *
The name you use when you go to the doctor
Street Address *
City *
State *
Zip Code *
Date of Birth *
MM
/
DD
/
YYYY
Sex assigned at birth *
Race *
Ethnicity *
Email for Appointment Confirmation *
Phone *
Format: 314-123-4567
Navigator Patient ID (optional)
If you registered at the covidvaccine.mo.gov/navigator and have your patient ID number (from the confirmation email) enter it here!
Everyone 16+ is now eligible to get a vaccine!
We want to get you an appointment! Answering this question is optional but helps!
Which days/times are you available? *
Please check all that apply - we want you to be able to make it to your appointment! Hint: The more times you're available, the quicker we'll be able to find you an appointment!
Not available
Available All Day
Before 7am
7am - 8am
8am - 9am
9am - 10am
10am - 11am
11am - 12pm
12pm - 1pm
1pm - 2pm
2pm - 3pm
3pm - 4pm
4pm - 5pm
5pm - 6pm
After 6pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Schedule Comments
Any special instructions go here! If you want us to book you with a friend please list their name (and make sure we have their form! Please tell us any special care you need here too (like an interpreter, etc.)!
Maximum Travel Ability *
How far can you go?
Health Screening (check any that apply) *
Required
How would you like to be contacted? *
Required
Which Dose Do you Need? *
If this is your first dose, which vaccine will you accept? Check all that apply. *
It takes longer to book appointments for people who need a specific vaccine - please be patient if you can only accept one kind!
Required
If you need a 2nd dose, what day was your 1st dose? *
Please only submit a form if you are due for your 2nd dose in the next 7 days! If this is your first dose, just put an "x"
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