Covid-19 Vaccination Request

Covid-19 Vaccination Instructions

Anyone who is eligible and who wants a vaccine will be required to sign up for a vaccine appointment through a special website. The office will not be scheduling appointments for Covid vaccines directly. In order to help us plan and ensure we have adequate vaccine supply, please answer the following questions and include an email address that you check regularly.

Question Title

* 1. Are you a patient at Achievable?

Yes

Question Title

* 2. Name

Question Title

* 3. How likely are you to get the Covid -19 vaccine?

I Want to Receive the Covid-19 Vaccine As Soon As Possible

I Want to Receive the Covid-19 Vaccine

I Want to Wait to Receive the Covid-19 Vaccine

I Am Unsure if I Want to Receive the Covid-19 Vaccine

I Do Not Want the Covid-19 vaccine

Question Title

* 4. Do you work in any of the following fields?

Childcare

Education

Emergency Services

Food and Agriculture

Healthcare/IHSS with Direct Patient Contact

I do not work in any of the above fields

Question Title

* 5. Are you age 50 or older?

Yes

Question Title

* 6. Do you have a chronic condition, disability or chronic illness that puts you/the person at a higher risk of serious illness and/or death from Covid-19?

Yes

Question Title

* 7. Please list the condition(s) here. Please be as specific (Ex. type of diabetes) as possible with your answer. If you have multiple conditions, please list all of them.

Question Title

* 8. Please write the best email address so we can contact you to schedule the vaccine appointment. You will be emailed a link to register for the vaccine and it will be administered by Achievable staff. If you do not have an email address, please write your phone number instead.