COVID-19 Vaccination List Local supply is currently limited and vaccine administration is based on state guidance which can be found on the Department of State Health Services website.Please enter your contact information in order to be notified when COVID-19 vaccines are available. This form will serve as a contact list to be used by the Brownwood/Brown County Health Department and Hendrick Brownwood when there are vaccines available for qualifying groups. The Health Department may share this list with local providers who have vaccines in order to expedite vaccine distribution. DISCLAIMER: Submitting information on the contact form does not guarantee a person and/or organization vaccines nor does it place individuals in a “queue”. Additionally, repeated submissions and calls inhibit our ability to respond in a timely manner. Please only submit when appropriate and only submit one per person/organization. Question Title * 1. Please enter your last name Question Title * 2. Please enter your first name Question Title * 3. What is your date of birth? Please select date of birth Date Question Title * 4. How old are you? Question Title * 5. Please enter your email address Question Title * 6. Please confirm your email address Question Title * 7. Please enter your telephone number Question Title * 8. Please enter your physical address (not a PO Box) Question Title * 9. Are you a first responder or medical professional? Yes No Question Title * 10. If you answered "yes" where are you employed? Question Title * 11. Do you have a chronic health condition such as (but not limited to) cancer, chronic kidney disease, COPD (chronic obstructive pulmonary disease), heart conditions (heart failure, coronary artery disease, or cardiomyopathies), solid organ transplant, obesity, pregnancy, sickle cell disease, type 2 diabetes mellitus? Yes No Question Title * 12. Have you received a vaccination within the last 14 days? Yes No Question Title * 13. If you answered "yes" which vaccine did you recieve? Question Title * 14. Have you had COVID-19? No. If yes, what date did you recover? Done