COVID-19 Vaccine Survey

1

Are you currently an established patient with Edinger Medical Group?* This field is required.

YESNO

2

Have you already received the COVID-19 vaccine at another location?* This field is required.

Yes

No

3

EMG is working to obtain the COVID-19 vaccine to administer to our patients that are 65 years of age or older. Would you be interested in getting the vaccine if we obtain it?* This field is required.

Yes

No

4

For documentation purposes, please complete the next slides. Thank you.

5

Name* This field is required.

First Name

Middle Name

Last Name

6

Date of Birth* This field is required.

Date

7

Best Contact Number* This field is required.

8

Email Address* This field is required.

example@example.com

Confirm Email

9

Unfortunately, you must be an established patient with Edinger Medical Group to receive the vaccine. If you would like to become an EMG patient, please call our office to get started 714-965-2500. Please do not call our office regarding the COVID-19 vaccine if you are not an existing patient. Thank you.

10

Thank you for taking the survey. We will update your record with this information and you will not be contacted for vaccine scheduling at EMG. Stay safe and well!