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We will begin Phase 3 when the patients in Phase 2 that wish to be vaccinated have been completed. This could take some time as we are still only getting limited doses every week. Once you complete this survey, you do NOT need to call in to the clinic to have your name put down on the list. We will call to schedule you once Phase 3 has begun. PLEASE COMPLETE ONE SURVEY FOR EACH PERSON IN YOUR HOUSEHOLD THAT WOULD LIKE TO BE VACCINATED. We are currently only accepting our patients at this time. 

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* 1. Name?

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* 2. Date of Birth?

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* 3. Age? 

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* 4. Best Phone Number to contact you?

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* 5. Do you have any of the following health conditions? Please select all that apply.

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* 6. Notes/Questions/Special Requests

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