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* 1. First Name

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* 2. Last Name

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* 3. Phone Number

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* 4. E-mail Address

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* 5. Your Birthdate (MM/DD/YYYY):

Date

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* 6. Which OCHC Clinic are you a patient?

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* 7. As we prepare to receive more COVID-19 Vaccines, we are looking at getting this out to the public through a variety of formats, based upon how many vaccines we receive.  There may be times when, to avoid wasting vaccine, we make last-minute calls to offer an appointment.  Please tell us if you could be at one of our medical locations (Hermitage or Urbana) within 45 minutes to take advantage of this opportunity.

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* 8. Are you already signed up on another waitlist with another organization

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* 9. We are following Missouri's vaccination plan for prioritization of those who will receive the vaccine.  Please let us know your category:

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