OCHC COVID-19 Vaccine Wait List

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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 / Time

Date

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* 6. Which OCHC Clinic are you a patient?

Hermitage - Medical/Behavioral Health

Hermitage - Dental

Urbana - Medical/Behavioral Health

Bolivar - Miles for Smiles

Greenfield - Dade Co. Dental Clinic

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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.

Yes

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

Yes

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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:

Phase 1A: Healthcare worker, EMS/EMT/Paramedics

Phase 1B Tier 1: First Responder & Emergency Services

Phase 1B Tier 2: Individuals older than 65, High Risk Individual (18-64) with Cancer, Chronic Kidney Disease, COPD, Intellectual and/or developmental disabilities, Heart conditions, Weakened immune system due to organ transplant, Severe obesity (BMI>40), Pregnancy, Sickle cell disease, Type 2 diabetes

Phase 1B Tier 3: Work in: Education, Childcare, Communications, Dams, Energy, Food/Agriculture, Government, IT, Nuclear, Materials and Waste, Transportation, Water and wastewater

Phase 2: Work in: Chemical sector, Commercial facilities sector, Critical manufacturing, Defense sector, Financial services sector, Food/Agriculture sector II, Government, Higher education, Disproportionally affected, Homeless

Phase 3: All Missouri Residents