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COVID-19 Vaccine Appointment Request Form

  1. Are you a healthcare worker (providing direct patient care)? / Eres un trabajador de salud?*

  2. Are you 75 or older? / Tienes 75 anos o mas?

    No longer required, please answer next question.

  3. Are you 65 or older? / Tienes 65 anos o mas?*

  4. Are you a Teacher?*

  5. Leave This Blank:

  6. This field is not part of the form submission.