MRFM COVID-19 Wait List Survey Please answer the following questions to be added to our COVID-19 vacc Question Title * 1. Enter your name: First name: Middle name: Last Name: Question Title * 2. Enter your date of birth: DOB Date Question Title * 3. What is your home phone number? Question Title * 4. What is your cell phone number? Question Title * 5. What is your email? Question Title * 6. Which doctor do you see at Mountain Region Family Medicine? Dr. Archer Dr. Baker Dr. Brandon Dr. Carter Dr. Cooper Dr. Delwadia Dr. DeMotts Dr. Eastridge Dr. Harman Dr. Karakattu Dr. Kauzlarich Dr. Metcalf Dr. Misischia Dr. Roller Dr. Sumpter Dr. Vincent Dr. Watson Question Title * 7. Have you had an allergic reaction to laxatives that contain polyethylene glycol (Miralax)? Yes No Question Title * 8. Have you had an allergic reaction to a vaccine or injectable medicine that required treatment with epinephrine (EpiPen) or treatment at the hospital? Yes No Question Title * 9. Do you currently have COVID symptoms or are you in isolation for COVID infection or exposure? Yes No Question Title * 10. Have you had IV antibodies for a COVID infection in the past 90 days? Yes No If yes, date if known: Question Title * 11. Have you had any other vaccine in the past 14 days? Yes No If yes, date if known: Question Title * 12. If we have a cancellation, prior to your scheduled appointment time, could you arrive within 30 minutes’ notice? Yes No Done
