COVID 19 WAITING LIST REGISTER Question Title * 1. Name Question Title * 2. Date of Birth Question Title * 3. Email Question Title * 4. Phone Number Question Title * 5. Are you a healthcare worker? Question Title * 6. Are you a longterm facility resident and/or staff? Question Title * 7. Are you over the age of 65+? Question Title * 8. Are you a caretaker of someone over the age of 65+? Question Title * 9. Medical conditions you currently have Question Title * 10. What insurance do you currently carry? Question Title * 11. Which office location is your preference for receiving the vaccination? A. 11375 Southbridge Parkway, Alpharetta GA 30022B. 777 West Peachtree Street, Norcross GA 30071 Alpharetta Office Norcross Office Either location is fine Done