COVID-19 Vaccine Interest Form

1
DISCLAIMER: By submitting this form you are granting Frederick Health permission to contact you via email and/or text message.
2
Are you a part of the Frederick Health Medical Group?* This field is required.
YESNO
3
Which location do you visit for care?Please select one location from the following list.
Crestwood
Mount Airy
Myersville
Liberty
Internal Medicine Associates (IMA)
Walkersville
Urbana
Toll House
4
Your Name:* This field is required.
First Name
Last Name
5
Email Address:* This field is required.
example@example.com
6
Cell Phone Number:* This field is required.Message & data rates may apply.
Area Code
Phone Number
7
Birth Date:* This field is required.
Date
Month
Day
Year
8
IMPORTANT NOTE: To review a list of underlying medical conditions that could potentially increase your risk for severe COVID-19 illness, please visit the official CDC website.
9
Do you have an underlying health condition that increases your risk for severe COVID-19 illness?* This field is required.
YESNO
10
Groups that are currently eligible to receive the vaccine:

All licensed, registered and certified health care providers

Front line hospital staff

Nursing home residents and staff

Individuals with intellectual and developmental disabilities

Assisted living, independent living, behavioral health and developmentally disabled group homes, and other congregate facilities

Law enforcement and firefighters, EMS

Education staff, including K-12 teachers, support staff and daycare providers

Correctional health care staff and officers

Public safety workers not covered in Phase 1A

Health care workers not covered in Phase 1A, including but not limited to lab services, public health, vaccine manufacturing and other health care professions

Front line judiciary staff

Continuity of government

Food/agriculture production, critical manufacturing, U.S. Postal Service, public mass transit, grocery store employees

Veterinarians and support staff

Clergy and other essential support for houses of worship

Adults age 60 and older

Individuals who are currently hospitalized AND diagnosed with the following criteria:

Cancer patients who are currently in active treatment

End stage renal disease patients requiring hemodialysis

Chronic Obstructive Pulmonary Disease (COPD), especially those who are

oxygen-dependent or are steroid dependent

Solid organ transplant recipients

Sickle cell disease patients

Diabetic patients (Type 1 and Type 2)

Individuals who are diagnosed with these medical conditions but are not currently hospitalized will be eligible to receive the vaccine in Maryland’s Phase 2 COVID-19 vaccine distribution.

Click here to learn more.
11
Do you meet the eligibility requirements to receive a vaccine?* This field is required.
YESNO
12
Please provide us with the name of your Primary Care Provider (PCP):
First Name
Last Name
13
All vaccinations are held at our Frederick Health Village location. CLICK HERE for directions.
14
If called, can you be onsite within 30 minutes?* This field is required.
YESNO
Should be Empty:

Groups that are currently eligible to receive the vaccine:

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