COVID-19 Vaccine Interest Survey

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Due to limitations in vaccine availability we are currently determining interest in COVID-19 vaccinations for patients age 65 and older.

Are you interested in receiving the COVID-19 vaccine? *

We would like to take this opportunity to update your contact information. Please provide your Name, date of birth, telephone number and email address.

This form is being completed by someone other than the patient.

Your Name *

Relationship to patient *

Preferred Primary Care Physicians may be partnering with local health systems to offer our patients an opportunity to receive the COVID-19 vaccine. To which of the following locations are you willing to travel to receive the vaccine?

PNC Park Jefferson Regional Hospital Canonsburg Hospital Pittsburgh International Airport

If other vaccination locations become available how far are you willing to travel to receive the vaccine?

Patient Name *

First Name Last Name

Patient Address *

Street Address

Street Address Line 2

City State

Zip Code

Race *

Ethnicity *

Patient Date of Birth *

Date

Contact Email *

Confirmation Email Confirm Email address

Contact Phone Number *

Please enter a valid phone number.

Phone Type *

Cell Phone Landline

What is the name of your Preferred Primary Care Physicians Provider? *

Please provide any additional information to support your selections above.

1000 character limit

Important Disclaimers *

Acknowledge

I understand submitting this form does not guarantee I will receive a vaccine. We are following the strict CDC and PA DOH guidelines on the prioritization of vaccinations.

We ask that you do not contact your physician's office for an update on when you will be getting your vaccination. We will contact you as soon as we have the vaccine in stock and you are eligible for the vaccination.

We will notify you via text message, email or by phone when you are eligible to schedule your vaccination appointment. Please check your email regularly for updates, especially your spam folder.

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