COVID-19 Vaccine Survey

First Name *

Last Name *

Date of Birth *

Phone number * Please use the format 000-000-0000.

Email Address (Will be used to send a survey confirmation email. You may receive an email invitation to schedule online)

What is your zip code?

What is your Medical History Number (MHN)? How do I find my MHN?

Preferred vaccine location.* (You may have the opportunity to receive the vaccine other than at your preferred location, depending on availability.)

We have interpreters available to help schedule your appointment. Please provide your primary language if this would be helpful.

What dose do you need to schedule? *

Which COVID-19 Vaccine product would you like to receive?

When was your last dose received? * (Don't guess! Please refer to your COVID-19 Vaccination Record Card. The details of your dose must be accurate.)

Which brand vaccine did you receive? * (Don't guess! Please refer to your COVID-19 Vaccination Record Card. The details of your dose must be accurate.)

Do you have a specific medical condition or are you receiving medical treatment that causes you to be moderately to severely immunocompromised? *

Yes No

Do you need transportation assistance getting to the vaccination location? *

Yes No

COVID-19 Vaccination Survey

12 Years or Older Qualify for COVID-19 Vaccine

6 Months to 11 Years Qualify for COVID-19 Vaccine

Step 2: Who is your employer or to what organization do you belong?

Patient personal information

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Our System

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