Tell us about who you are so we can contact you when the vaccine is available.
Date of Birth: MM123456789101112 / DD12345678910111213141516171819202122232425262728293031 / YYYY2000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901
Please answer the following questions so we can determine which COVID-19 vaccination phase applies to you.
Are you a healthcare employee or professional (Do you work in one of the following: hospital, long-term care facilities, outpatient clinic, home health care, pharmacy, emergency medical service, or public health)?
YesNo
Are you a resident of a long-term care facility (skilled nursing facility, assisted living facility, or other residential care)?
Are you an essential worker (Do you work in education, food & agriculture, utilities, police, firefighter, corrections officer, or transportation)?
Do you have a high-risk medical condition (i.e. cancer, chronic kidney disease, COPD, diabetes, heart conditions such as heart failure, coronary artery disease, or cardiomyopathies, obesity (BMI > 30 kg/m2), pregnancy, sickle cell disease, and/or smoking)
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Due to overwhelming vaccine registrations and unavailability of vaccine, We have paused online registration for Covid-19 vaccine.
