COVID-19 Vaccine Wait List Form
If you would like us to advise you of the availability of the COVID-19 vaccine when it is made available to the public, please provide the following information. Please note, we are focusing vaccination efforts on our local Southern Humboldt community (Redcrest to Piercy). For those outside the area, please contact public health for information about the nearest alternative vaccination site at (707) 441-5000.
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Age
*
Gender
Female
Male
Email
example@example.com
Phone Number - Main Contact
*
Please enter a valid phone number.
Phone Number - Alternative
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Are you an essential worker (e.g. food service, police, firefighter, agriculture, education, IT)?
*
Yes
No
Please list your employer or place of employment (to prioritize essential workers):
Health and Medical History
Do you have any of these underlying conditions? Adults of any age with the following conditions are at increased risk of severe illness from the virus that causes COVID-19.
Cancer
Chronic kidney disease
COPD (chronic obstructive pulmonary disease)
Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
Immunocompromised state (weekend immune system) from solid organ transplant
Obesity (body mass index [BMI] of 30 kg/m2 or higher but
Severe Obesity (BMI >40 kg/m2)
Pregnancy
Sickle cell disease
Smoking
Type 2 diabetes mellitus
Do you have any of these underlying conditions? Based on what we know at this time, adults of any age with the following conditions might be at an increased risk of severe illness from the virus that causes COVID-19.
Asthma (moderate-to-severe)
Cerebrovascular disease (affects blood vessels and blood supply to the brain)
Cystic fibrosis
Hypertension or high blood pressure
Immunocompromised state (weekend immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
Neurologic conditions, such as dementia
Liver disease
Overweight (BMI>25 kg/m2, but < 30 kg/m2)
Pulmonary fibrosis (having damaged or scarred lung tissues)
Thalassemia
Type 1 diabetes mellitus
For eventual scheduling purposes, please let us know if you are currently a Redwoods Rural Health Center patient?
Yes
No
For information on this and actions that you can take to keep yourself safe, visit the CDC website at https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html.
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