General Population COVID-19 Vaccine Interest Form
Name
*
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
What is your race (please select only one)
*
Black or African American
Asian or Pacific Islander
Native American or Alaskan Native
White
Other
Prefer not to answer
What is your ethnicity?
*
Hispanic
Non-Hispanic
Prefer not to answer
What is your preferred language?
*
Ex. English, Spanish, Hmong
We have no control over what brand of vaccine we are going to receive each week. We strongly encourage that you take whatever appointments are available. If you can only receive a certain brand of vaccine, we cannot guarantee that we will be able to provide it to you. We urge you to contact your primary care provider or other vaccination sites, as they may be able to accommodate your request.
Are there any COVID-19 vaccine brands that you are unable to receive due to medical reasons? *If you are younger than 18, you may only receive the Pfizer vaccine*
*
Moderna
Pfizer
Johnson & Johnson
None
What is your preferred form of communication? This is how you will be contacted to schedule your appointment. If you select text message or email, you will receive a link to sign up. Phone calls will be from a Buffalo County Public Health employee.
*
Text Message
Email
Phone Call
I have read and understand the texting informed consents policy.
Clear
By checking this box, I hereby agree that the information I have given in this form is accurate and complete. I release and discharge this information to all the employees, administrators, agents and governmental bodies from any and all claims.
*
Submit
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