COVID-19 Vaccine Request Form
The demographic information collected below is required for federal and state reporting purposes and will help to expedite the scheduling process once you become eligible for the vaccine.
*
= Required Field
Personal Information
First name
*
Middle name
Last name
*
Sex assigned at birth
*
--
Female
Male
Prefer not to answer
Date of birth (MM/DD/YYYY)
*
Email
*
Ethnicity
*
--
Hispanic
Non Hispanic
I Prefer not to answer
Race
*
--
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Two or more races
I Prefer not to answer
Phone Number
Primary contact number
*
What type of phone number is this?
*
Mobile
Home
Secondary contact number
What type of phone number is this?
Mobile
Home
Address
Residential Address
*
Apartment, Suite, Unit, etc. (Optional)
City
*
State
*
--
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
NE
NH
NJ
NM
NV
NY
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WI
WV
WY
Zip code
*
Are you currently receiving care through the Veterans Administration (VA)?
*
Yes
No
Do you have any existing health conditions?
*
Yes
No
Have you already received the first vaccination?
*
Yes
No
Have you ever been a patient of MedStar Health?
*
Yes
No
I have verified this information and confirm that it’s true.
I have reviewed a copy of the
Notice of Privacy Policies
.
Submit
