If you have already received a COVID-19 vaccine, please provide the following information so we can update your medical chart. Thank you

1.

Full Name *

2.

Date of Birth (mm/dd/yy) *

3.

What was the date of your COVID-19 Booster?

4.

Vaccine Manufacturer for COVID-19 Booster?

5.

Lot Number of your Booster dose (if known)?

6.

Where did you receive your COVID-19 booster?

The following questions are for your first and second vaccinations. Complete this only if you haven't previously reported this to DRFP.

7.

Date of your 1st COVID-19 vaccination?

8.

Vaccine Manufacturer?

9.

Lot Number of your 1st COVID-19 vaccine (if known)?

10.

Date of your 2nd of COVID-19 vaccination (if applicable)?

11.

Lot Number of your 2nd COVID-19 vaccine (if known)?

12.

Where did you receive your COVID-19 vaccine?