COVID-19 Vaccine Clinic May 10 from 2:00 PM - 7:00 PM

Mission Medical will be getting COVID-19 Vaccines.
This is to schedule a COVID-19 Vaccination.
Now everyone over 18 is eligible for the Moderna vaccination.

A Mission Medical team member will reach out to you

within 48 hours to finalize an appointment on

Monday, May 10 from 2:00 - 7:00 PM.

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* 1. Contact Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Birthday

Date / Time

Date

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* 3. Medical Conditions

Diabetes

High Blood Pressure

Cancer

Chronic Kidney Disease

COPD

Heart Conditions

Obesity

Pregnant

Asthma

None of the above

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* 4. Have you tested positive for COVID-19?

Yes

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* 5. Gender

Female

Male

Prefer not to say

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* 6. Race

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race