Are you in the Phase 1B Priority Group?
YesNo

To Which Phase 1B Priority Group Do You Belong?
More Information
Persons aged 65 years and overTier 1Tier 2Tier 3Tier 4Tier 5

First Name *Required

Last Name *Required

Gender *Required

Age *Required

Date of Birth *Required
Format: MM/DD/YYYY

Occupation
Enter "N/A" if not applicable

Organization Name
Enter "N/A" if not applicable

Home Address *Required

City *Required

State *Required

ZIP *Required

Phone Number *Required
Format: XXX-XXX-XXXX

Primary Provider

Are you actively being treated for cancer, COPD, Asthma, or diabetes?
YesNo

Have you received treatment for COVID-19 in the last 90 days. (ie: Monoclonal Antibody Infusion: Bamlanivimab 'BAM', Casirivimab/Imdevimah 'Regeneron', Convalescent Plasma)
YesNo

Do you need an interpreter?
YesNo