CLOSED: COVID-19 Vaccine Registration Form

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WE ARE NO LONGER ACCEPTING NEW REGISTRATIONS

Legal First Name *

Legal Last Name *

Preferred Name

Birth date *

YYYY

Age *

Gender assigned at birth *

Female

Male

Phone Number (xxx-xxx-xxxx) - you must leave a number where you can be reached to schedule an appointment. *

Is this above a mobile phone? *

Yes

Can you receive and reply to text messages at this number? *

Yes

Street Address *

Zip code *

Race *

Ethnicity *

Primary Insurance - while the vaccine is free, there is a small administration fee that is billed to insurance. It is mandated that patients will have no out of pocket cost. *

Medicare

Blue Cross Blue Shield

United

Sunflower Health Plan (KanCare)

United Health Care Community (KanCare)

Aetna Better Health (KanCare)

None/ Uninsured

Other:

Policy Number or Insured ID (if none, skip to next question)

Primary Medical Clinic - if you'd like us to share your name with your primary care clinic when/if they receive vaccines, please indicate your primary care clinic.

ComCare Ohio

ComCare Santa Fe

ComCare Minneapolis

Mowery Clinic

Salina Pediatrics

Salina Family Healthcare Center

Other:

Clear selection

Do you live or work in Saline County? *

Yes

Are you a healthcare worker, who is likely to be exposed to or treat people with COVID-19 or infectious materials and are unable to work from home? (Examples: nurse, mortician, home health aid, dentist, chiropractor, veterinarian) *

Yes

Do you reside in a congregate setting? (i.e. facilities that are licensed by the state or local government, that provide housing or care arrangements and where social distancing is not possible; they provide a form of social service, healthcare, or healthcare-associated service) *

Yes

Are you a high-contact critical worker as defined by the Dept. of Homeland Security? If you are a high contact critical worker, what industry are you in?

Firefighters, police officers, first responders, corrections officers

Grocery store and food services

K-12 and childcare workers: teachers, custodians, drivers, etc.

Healthcare

Food processing, including meat processing plants

Large scale aviation manufacturing plants

Transportation workers

Workers in retail, agriculture, supply of critical services or materials for COVID-19 response

The US Postal Service / Department of Motor Vehicles

Not applicable

Other:

Clear selection

Are you a person who is at increased risk for severe illness or other medical risks from COVID-19, including those with underlying medical conditions such as cancer, chronic kidney disease, chronic obstructive pulmonary disease, heart conditions, obesity, sickle cell disease, smokers or those with a history of smoking, type 2 diabetes, or immunocompromised? *

Yes

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