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* 1. Your Name

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* 2. Date of Birth (mm/dd/yyyy)

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* 3. Cell Phone Number

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* 4. Alternative Phone Number

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* 5. How old are you?

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* 6. Do you have one of the following underlying conditions? 

Cancer, Chronic kidney disease, COPD, Heart conditions (heart failure, coronary artery disease or cardiomyopathies), Solid organ transplantation, Obesity and severe obesity (body mass index of 30 kg/m2 or higher), Pregnancy, Sickle cell disease, Type 2 diabetes mellitus

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* 7. Are you currently a registered patient with ETCHSI?

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