The COVID-19 Vaccine is now available to all persons aged 5 and older.  There is no residency requirement.  This survey will help PMC schedule people in a fair and safe manner.  This survey is HIPAA compliant and your personal information is needed to put you on a waiting list.    

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* 1. Is this survey for someone who is 17 years or younger?

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* 2. Last Name

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* 3. First Name

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* 4. What is your date of birth?  (MM/DD/YYYY)

Date

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* 5. Day Phone Number:

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* 6. Mobile Phone Number:

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* 7. Email address: 

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* 8. What is your preferred way of contact?

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* 9. Please indicate vaccine preference, and if you need dose 1, 2 or booster.  Also, additional information about your availability.   

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* 10. Would you like information or instructions in your native language?  

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