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* 1. What is your contact information so we can reach you to schedule an appointment when you qualify for the vaccine?

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* 2. What is your age?

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* 3. Date of Birth?

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* 4. Have received any other vaccines in the last 14 days?

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* 5. Do you have any preexisting medical conditions, if so what are they?

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* 6. Are you an essential worker? if so, who is your employer?

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* 7. Sex:

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* 8. Race:

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* 9. Hispanic Ethnicity?

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