Covid 19 Application

First Name*

Middle Name*

Last Name*

Mailing Address*

City*

State*

Zip*

Phone Number*

Email Address*

Date of Birth*

(must be 18 or older)

Bond Clinic Physician Name (if multiple you only need to list one):

Questions

1. Are you 18 years old or older? (You must be 18 or over to to be scheduled for a vaccination)

NoYes

2. Have you previously received a COVID-19 vaccine? (Do not apply if you have already received a COVID vaccination.)

NoYes

3. Have you received another vaccine (including Flu vaccine) in the last 2 weeks? (Do not apply if you have recently received another vaccination in the last 2 weeks.)

NoYes

4. Have you had a COVID positive test or had COVID symptoms in the last 10 days? (You cannot apply if you have tested positive for COVID in the last 10 days)

NoYes

5. Have you been treated with antibody therapy for COVID-19 in the last 3 months? (You cannot apply if you have been treated with COVID-19 antibody therapy in the last 3 months)

NoYes