Please answer this series of questions to help us to confirm your current eligibility to receive the COVID-19 vaccine. If an answer to a question indicates you are eligible, the next question will automatically appear.
Finally, you will be asked to check the Verify box, confirming your eligibility. When you check the box, a scheduling calendar will appear for you to schedule your vaccination, if appointments are currently available.
I certify that I am at least 18 years of age, or the parent or legal guardian of the minor patient.
I have read the relevant links available on this page and hereby give my consent to the licensed healthcare provider administering the vaccine, as applicable (each an "applicable Provider"), to share my personal, demographic and health condition information in order to provide me with vaccination services for the COVID-19 vaccine. I understand that the health data shared within this questionnaire will be used to determine my eligibility for receiving the COVID-19 vaccination and further determine timing of when the vaccine will be made available to me.