Mobridge Regional Hospital and Clinics is proud to be working with the South Dakota Department of Health to administer COVID-19 vaccines in our area. We understand that many are interested in receiving the vaccine and want you to know that we are working as quickly as possible to administer the vaccine as it becomes available to our area. We are currently working with Campbell, Corson, Dewey and Walworth with support to Ziebach and Perkins counties to administer vaccine according to the priority groups outlined by the South Dakota Department of Health. You are welcome to submit your information through this survey.

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* 1. Which COVID-19 Priority Group for phase 1 of vaccination as outlined by the South Dakota Department of Health do you fall into?
(Please check the response that is highest on the list)

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* 2. Do you have any of the following chronic illnesses?
(Please check all that apply)

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* 3. Please provide the following contact information

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* 4. What is your date of birth?

Date

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* 5. Are you currently undergoing treatments for cancer?

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* 6. Are you undergoing kidney dialysis?

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* 7. Have you received a transplant?

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* 8. Are you able to come to Mobridge with only 30 minutes notice?

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* 9. What is your current age?

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