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City of Pharr COVID-19 Vaccine Interest Form
It is our intention to gather data on individuals that are interested in receiving the COVID-19 vaccine. Filling out this form WILL NOT register you to receive a vaccine. We will not share any of your information as it is strictly used to conduct informed planning for vaccinations.
Patients Full Name:
*
First Name
Middle Name
Last Name
Address
*
Street Address
Apt. / Suite/ Lot #
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth:
*
/
Month
/
Day
Year
Date Picker Icon
Phone:
*
Please enter a valid phone Number.
Email
*
example@example.com
Gender:
*
Male
Female
Race:
*
Hispanic or Latino
Not Hispanic or Latino
Ethnicity:
*
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
Asian
White
Black or African American
Other
Are you one of the following?:
*
First Responder
Healthcare Worker
65 years or older and bedridden or homebound
Person under age of 65 with underlying medical conditions
Resident of a care facility or adult day care
Veteran
No, I am not any of the above
Are you one of the following?:
*
First Responder
Healthcare Worker
Person under age of 65 with underlying medical conditions
Resident of a care facility or adult day care
Veteran
No, I am not any of the above
Submit
Should be Empty: