COVID-19 Vaccine Interest Form • SoHum Health

Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP
Date of Birth*
Do you have any of these underlying conditions?
Adults of any age with the following conditions are at increased risk of severe illness from the virus that causes COVID-19.
- Cancer
- Chronic kidney disease
- COPD (chronic obstructive pulmonary disease)
- Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
- Immunocompromised state (weakened immune system) from solid organ transplant
- Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)
- Severe Obesity (BMI ≥ 40 kg/m2)
- Pregnancy
- Sickle cell disease
- Smoking
- Type 2 diabetes mellitus
Do you have any of these underlying conditions?
Based on what we know at this time, adults of any age with the following conditions might be at an increased risk for severe illness from the virus that causes COVID-19.
- Asthma (moderate-to-severe)
- Cerebrovascular disease (affects blood vessels and blood supply to the brain)
- Cystic fibrosis
- Hypertension or high blood pressure
- Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
- Neurologic conditions, such as dementia
- Liver disease
- Overweight (BMI > 25 kg/m2, but < 30 kg/m2)
- Pulmonary fibrosis (having damaged or scarred lung tissues)
- Thalassemia (a type of blood disorder)
- Type 1 diabetes mellitus
For eventual scheduling purposes, please let us know if you are currently a SoHum Health Clinic patient?*
- Yes
- No
*
- By completing this form, you authorize us to communicate with you via email, phone, or mail, regarding the provision of service, and that any information shared by you may be included in those communications. You are under no obligation to receive services from us when they are offered.