COVID-19 Vaccine Screening First Name * Last Name * Date of Birth (dd/dd/yyyy format) * Age * Gender * Male Female Phone * Email * Race * American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White or Caucasian Other Ethnicity * Hispanic or Latino Not Hispanic or Latino Decline to Answer Address (P.O. Boxes are NOT a Valid Address) * City * State * Zip Code * Primary Care Provider (PCP) Name * PCP Address * PCP Phone * Are you feeling sick today? (Fever, Respiratory Infection, or other moderate/severe illness) * Yes No In the last 10 days, have you had a COVID-19 test or been told by a healthcare provider or health department to isolate or quarantine for COVID-19 infection or exposure? * Yes No Have you received antibody therapy (monoclonal antibodies or convalescent plasma) for COVID-19 in the past 90 days (3 months)? * Yes No Have you had any vaccines in the past 14 days (2 weeks) including flu shot? * Yes No If you are human, leave this field blank. Submit Δ
