COVID Vaccination Registration
*
1.
Your Name
(Required.)
*
2.
Date of Birth (mm/dd/yyyy)
(Required.)
*
3.
Cell Phone Number
(Required.)
4.
Alternative Phone Number
*
5.
How old are you?
(Required.)
<15
16-64
65-74
75+
*
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
(Required.)
Yes
No
*
7.
Are you currently a registered patient with ETCHSI?
(Required.)
Yes
No
Current Progress,
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