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• Cerebrovascular Disease • Chronic Obstructive Pulmonary Disease • Chronic Kidney Disease • Cystic Fibrosis • Hypertension or High Blood Pressure • Type 1 Diabetes Mellitus • Type 2 Diabetes • Immunocompromised from solid organ transplant • Immunocompromised state (weakened immune system) • Liver Disease • Neurologic conditions, such as Dementia • Obesity • Overweight (BMI > 25 kg/m2, but < 30 kg/m2) • Pregnancy • Pulmonary Fibrosis (having damaged or scarred lung tissues) • Sickle Cell Disease • Smoker • Thalassemia (a type of blood disorder) •
(a) at least 18 years of age (b) the parent or legal guardian of the minor patient; or (c) the legal guardian of the patient. Further, I hereby give my consent to the licensed healthcare provider administering the vaccine, as applicable(each an “applicable Provider”), to share my personal, demographic and health condition information in order to provide me with vaccination services for the COVID-19 vaccine. I understand that the health data shared within this questionnaire will be used to determine my eligibility for receiving the COVID-19 vaccination and further determine timing of when the vaccine will be made available to me.
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