Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Do you have a QuadMed MyChart account?
Yes
No
Do any of the below conditions apply to you?
*
Yes
No
Asthma Diabetes Obesity Heart conditions Pregnancy COPD (Chronic obstructive pulmonary disease) Organ transplant Sickle cell diseae Taking immunity supressive medications
Do you provide care to anyone with the high risk conditions listed above?
*
Yes
No
Are you a health care worker?
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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