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COVID-19 vaccine pre-enrollment form

Thank you for your interest in receiving the COVID-19 vaccine.

Only the following people are currently eligible to receive the COVID-19 vaccine at CHoR and should complete this form:

  • CHoR patients ages 16+
  • Parents/caregivers of CHoR patients

How to enroll

  • All vaccine clinics are currently full.
  • We are actively adding vaccine clinics to the schedule (as supply allows). Complete the form below and we’ll call you when a new vaccine clinic opens.
  • Parents/caregivers and children 16+ can register together on one form.
  • We are vaccinating up to two parents/caregivers per CHoR patient.
  • Note: Children under 16 are not yet eligible to receive the COVID-19 vaccine.
  • We recommend also registering with your local health district so you can be vaccinated as soon as vaccine becomes available, either through your health district or CHoR.

Important note about scheduling

  • In order to streamline vaccine clinic processes, we ask that you please not call us to inquire about scheduling an appointment. We will call you to schedule as vaccine becomes available.
  • If you receive a call or text from us about scheduling a vaccine appointment, please DO call us back!
  • Children under 16 are not yet eligible to receive the COVID-19 vaccine.

CHoR patient information

CHoR patient name
Nombre del paciente de CHoR 
 *
Is your child 16+ or over with a comorbidity  *Does your child 16+ wish to receive the vaccine? CHoR patient date of birth (MM/DD/YYYY)
Fecha de nacimiento del paciente de CHoR (mes/día/año) 
 *
Please list at least one specialty/department your child is followed by
Por favor, enumere al menos uno de los departamentos/especialidades donde su hijo tiene consulta 
 *

Parent and caregiver information

First name of parent/caregiver #1
(Nombre del padre/madre/cuidador #1) 
 *
Last name of parent/caregiver #1
Apellido del padre/madre/cuidador #1 
 *
First name of parent/caregiver #2
Nombre del padre/madre/cuidador #2 
Last name of parent/caregiver #2
Apellido del padre/madre/cuidador #2 
Email
Correo electrónico 
 *
Cell phone number
Número de teléfono del celular 
 *
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