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Vaccine Contact

Date of Birth (required)*

Select your birth month from the dropdown, then enter your birth day, followed by your birth year.
E.g. January 01, 1990

Please select one or more practices where you are a current patient (if applicable):

Do you have one or more of the qualifying conditions below? (required)*

  • Asthma
  • Cancer
  • Cerebrovascular disease (affects blood vessels and blood supply to the brain)
  • Chronic kidney disease
  • Chronic liver disease (cirrhosis, chronic hepatitis)
  • COPD (chronic obstructive pulmonary disease) or chronic lung disease
  • Cystic fibrosis
  • Diabetes mellitus, Type 1 or 2
  • Down syndrome
  • Heart conditions (heart failure, coronary artery disease, or cardiomyopathies)
  • Hypertension (high blood pressure)
  • Immunocompromised (due to transplantation, HIV, immune deficiencies, etc.)
  • Liver disease
  • Neurological conditions, such as dementia
  • Obesity (body mass index over 30)
  • Overweight (body mass index over 25)
  • Pregnancy
  • Pulmonary fibrosis (damaged or scarred lung tissues)
  • Sleep apnea
  • Sickle cell disease
  • Smoking (current or former cigarette smoker)
  • Thalassemia (a type of blood disorder)

Please select one or more conditions (required)*