COVID-19 Vaccination Registration After completing this form, you will be redirected to our Patient Portal to complete your registration.SEE INSTRUCTIONS BELOW FOR OUR PATIENT PORTAL Name Phone Number Email In order to receive a vaccine at this time you must meet one of the following criteria. Healthcare Worker Teachers or School Faculty Social Services Employee Other Frontline Worker 65 years of age and older Cancer Chronic kidney disease COPD (chronic obstructive pulmonary disease) Heart conditions, such as heart failure, coronary artery disease or cardiomyopathies Solid organ transplantation Obesity and severe obesity (body mass index of 30 kg/m2 or higher) Pregnancy Sickle cell disease Asthma Type 1 or 2 diabetes If you are a Healthcare Worker, Teacher, Social Services Employee, or Other Frontline Worker, please list your place of employment. Send Click “SEND” above to be redirected to our Patient Portal (You do not need to be a patient)From there, click on “Pre-Register” at the bottom right corner of your screen and complete the formAfter completing this form, you will be contacted with instructions on receiving your vaccinationYou Only Need To Complete This Form ONCE