Please answer the following questions to be added to our COVID-19 vaccine wait list.

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* 1. Enter your name:

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* 2. Enter your date of birth:

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* 3. What is your home phone number?

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* 4. What is your cell phone number?

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* 5. What is your email?

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* 6. Do you have a COVID-19 vaccine preference?

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* 7. Have you had an allergic reaction to laxatives that contain polyethylene glycol (Miralax)?

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* 8. Have you had an allergic reaction to a vaccine or injectable medicine that required treatment with epinephrine (EpiPen) or treatment at the hospital?

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* 9. Do you currently have COVID symptoms or are you in isolation for COVID infection or exposure?

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* 10. Have you had IV antibodies for a COVID infection in the past 90 days?

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* 11. Have you had any other vaccine in the past 14 days?

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* 12. If we have a cancellation, prior to your scheduled appointment time, could you arrive within 30 minutes’ notice?

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