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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

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Phone Number

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What type of phone number is this?*

What type of phone number is this?

Address

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Are you currently receiving care through the Veterans Administration (VA)?*

Do you have any existing health conditions?*

Have you already received the first vaccination?*

Have you ever been a patient of MedStar Health?*