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* 1. Name

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* 2. Date of Birth

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* 3. Email

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* 4. Phone Number

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* 5. Are you a healthcare worker?

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* 6. Are you a longterm facility resident and/or staff?

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* 7. Are you over the age of 65+?

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* 8. Are you a caretaker of someone over the age of 65+?

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* 9. Medical conditions you currently have

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* 10. What insurance do you currently carry?

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* 11. Which office location is your preference for receiving the vaccination? 

A. 11375 Southbridge Parkway, Alpharetta GA 30022

B. 777 West Peachtree Street, Norcross GA 30071

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