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REQUIRED FIELDS

Please fill all the Required fields to ensure that all necessary information is captured for clinical and billing purposes.

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DEMOGRAPHIC INFO

Please fill out the fields below to provide additional information and to ensure proper identification during the testing and vaccination process.

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Affirmation Statement

I affirm that I meet one of the 1A criteria listed below
  • Health care personnel including, but not limited to:
    • Emergency medical service personnel
    • Nurses
    • Physicians
    • Dentists
    • Dental hygienists
    • Chiropractors
    • Therapists
    • Phlebotomists
    • Pharmacists
    • Technicians
    • Pharmacy technicians
    • Health professions students and trainees
    • Direct support professionals
    • Clinical personnel in school settings or correctional facilities
    • Contractual HCP not directly employed by the health care facility
    • Persons not directly involved in patient care but potentially exposed to infectious material that can transmit disease among or from health care personnel and patients
    • Persons ages 65 and older
    • Persons ages 16-64 with high risk conditions
  • Cancer
  • COPD
  • Down Syndrome
  • Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
  • Immunocompromised state (weakened immune system) from solid organ transplant or from blood or bone marrow transplant, immune deficiencies , HIV, use of corticosteroids, or use of other immune weakening medicines
  • Obesity (BMI of 30 kg/m2 or higher but &#62 40 kg/m2)
  • Severe obesity (BMI &#8805 40 kg/m2)
  • Pregnancy
  • Sickle cell disease
  • Smoking
  • Type 2 diabetes mellitus



I cannot affirm