Date of Birth*

What type of Vaccination are you interested in? (Check all that apply)*

Do you feel sick, have a fever, or other symptoms?*

Have you been diagnosed with of tested positive for COVID in the past two weeks?*

Have you been in close contact with someone who has tested positive for COVID in the past two weeks?*

Do you have a history of allergic reactions or allergies to latex, medications, food, or vaccines? (examples: polythylene glycol, polysorbate, eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast, thimersol, etc.)*

Have you ever had a reaction after receiving a vaccination, including fainting or feeling dizzy?*

Have you ever had a seizure disorder for which you are on seizure medication, a brain disorder, Gullian-Barre' Syndrome (a condition that causes paralysis) or other nervous system problems?*

Have you received any vaccinations or skin tests in the past 8 weeks?*

If you have ever been vaccinated for Pneumonia, please provide your best estimate of when that was.

If you have ever been vaccinated for Shingles, please provide your best estimate of when that was.

If you have ever been vaccinated for Whooping Cough, please provide your best estimate of when that was.

Do you have any chronic health conditions such as cancer, chronic kidney disease, immunocompromised, chronic lung disease, obesity, sickle cell disease, diabetes, asthma, or heart disease?*

Are you pregnant or considering becoming pregnant in the next month or are you nursing/ breast feeding?*