Carpenters Health Plan COVID-19 Vaccine Pre-Registration

Carpenters Wellness Center is an approved vaccinator site. We are working hard to acquire the vaccine. If we are allocated additional doses from the state, we need to know in advance how many members are interested in receiving the vaccine. Please complete this pre-registration survey if you are interested in receiving the COVID-19 vaccination through the state of Missouri in partnership with Carpenters Health Plan, Cerner and Carpenters Wellness Center.

We will be in contact with you IF the vaccine becomes available.

If you have previously completed this survey, please DO NOT complete it again.

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* 1. Please provide your full legal name (First, Middle, Last):

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* 2. In what state do you live?

Illinois

Missouri

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* 3. Please complete your best contact information:

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address

Phone Number *

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* 4. Which Priority Phase for COVID-19 vaccinations are you in? Please review the Missouri Priority Phases for vaccinations here.

Phase 1A

Phase 1B - Tier 1

Phase 1B - Tier 2

Phase 1B - Tier 3

Phase 2

Specific Qualifier (please specify)

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* 5. Do you have a history of allergic reactions to vaccinations or medications?

Yes

Carpenters Health Plan COVID-19 Vaccine Pre-Registration

Question Title

* 1. Please provide your full legal name (First, Middle, Last):

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* 2. In what state do you live?

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* 3. Please complete your best contact information:

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* 4. Which Priority Phase for COVID-19 vaccinations are you in? Please review the Missouri Priority Phases for vaccinations here.

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* 5. Do you have a history of allergic reactions to vaccinations or medications?

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* 6. What is your age?