COVID Vaccine Consent Form

COVID Vaccine Clinic Signup (STEP 1)
Please read this entirely and fill out the required details below. This form is HIPAA Compliant.
VACCINES DOSES AVAILABLE: 600
TO USE THIS FORM:
- Clone RESERVE A DOSE template and COMPLETE RESERVATION template
- Open cloned COMPLETE RESERVATION and go to the PUBLISH tab
- Copy the URL
- On the cloned RESERVE A DOSE, go to SETTINGS and then THANK YOU
- Put the new URL before the question mark
- It should be: yournewurl?catchRandom={input87}
- Be sure to test submission on RESERVE A DOSE, clicking the Thank You link, and completing COMPLETE RESERVATION
- You should see the secret code on BOTH submission tables
This clinic is currently reserved for patients 65 and over.
This is a TWO PART submission process.
STEP 1: Fill out this screening form and hit SUBMIT.
STEP 2: Take a deep breath; you got a spot! Fill out the form in STEP 2 to finalize your submission.
Please enter your Date of Birth*
MonthDayYear
Date
What dose of COVID-19 vaccine will this be?*
First DoseSecond Dose
Have you been treated for COVID using those fancy antibody treatments in the last 90 days?*
YesNo
Have you had ANY OTHER vaccines in the last 14 days?*
YesNo
You are not eligible for this clinic.
This clinic is for the first dose of patients 65 or older who have not been treated with COVID antibodies in the last 90 days or have not had any other vaccine within 14 days.
Enter your LAST NAME ONLY
Enter your email address
example@example.com
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
WHEN YOU HIT SUBMIT, YOUR DOSE WILL BE RESERVED AND YOU WILL BE SENT TO STEP 2
Should be Empty:

COVID Vaccine Clinic Signup (STEP 1)