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  • SARS-COV-2 Vaccine Notification Survey

    "COVID-19 Vaccine Notification and Distribution Survey"
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  • Review the below list of conditions known to increase risk of severe illness to COVID-19:

    •Asthma •Cancer •Cerebrovascular Disease •Chronic Obstructive Pulmonary Disease •Chronic Kidney Disease •Cystic Fibrosis •Hypertension or High Blood Pressure •Type 1 Diabetes Mellitus •Type 2 Diabetes •Immunocompromised from solid organ transplant•Immunocompromised state (weakened immune system) •Liver Disease•Neurologic conditions, such as Dementia •Obesity •Overweight (BMI > 25 kg/m2, but < 30 kg/m2) •Pregnancy •Pulmonary Fibrosis (having damaged or scarred lung tissues) •Sickle Cell Disease •Smoker •Thalassemia (a type of blood disorder)

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  • Parent or Guardian Consent Required: Because you will not be 18 years of age by 12/15/2020

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  • Waiver / Consent

    • I authorize Polk County Health and Human Services Agency (Polk County HHSA) to contact me regarding obtainment of a SARS-COV-2 ("COVID-19") Vaccine.

    • I confirm that medical professionals can reach me by telephone/mobile phone or email as part of this process.

    • I acknowledge that in this type of platform technical difficulties may happen which might cause a slight delay in response.

    • I accept that I can withdraw this waiver any time and it will not affect my situation when I need care or assistance in the future.

    • I confirm that by completing and submitting this form I agree to the collection of personal medical data or other personal health information (PHI) by the Polk County HHSA for the purpose of providing me with information regarding a SARS-COV-2 Vaccine.
    • I confirm that the information I provided here will not be shared with others without my consent.

    • I confirm that all information I provided in this online session is accurate and true.
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