Name
*
First Name
Last Name
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Do you have a QuadMed MyChart account?
*
Yes
No
Please select if any of the following conditions apply to you:
Asthma
Diabetes
Obesity
Heart conditions
Pregnancy
COPD (Chronic obstructive pulmonary disease)
Organ transplant
Sickle cell disease
Taking immunity supressive medications
Do you provide care to anyone with the high risk conditions listed above?
Yes
No
Are you a front line essential worker, such as first responders, corrections officers, education sector, U.S. Postal Service, food and agricultural workers?
Yes
No
Are you considered an other essential employee for instance transportation, logistics, utilities, food service, housing, finance, IT and telecom, energy, legal, media, public safety, defense contractors, public health employee?
Yes
No
The information collected will be used by QuadMed for the purpose of ordering supply of the vaccine and notifying you when you are eligible to schedule an appointment for the vaccine, based on the criteria set forth by the CDC and state guidance.
SUBMIT
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