Camarillo UMC - Vaccination

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Is this your first or second COVID-19 vaccination?
First
Second

Have you previously received a COVID-19 vaccine?
Yes
No
I don't know

Do you have any of the following chronic health conditions? (Cancer, Chronic kidney disease, COPD, Heart conditions, Immunocompromised state, Severe Obesity (BMI ≥ 40kg/m2), Pregnancy, Sickle cell disease, Smoking, Type 2 diabetes)?
Yes
No

Do you currently have a physical or mental disability that is so severe and high-risk that one of the following applies: 1) a COVID-19 infection is likely to result in severe, life-threatening illness or death; OR 2) acquiring COVID-19 will limit your ability to receive ongoing care or services vital to your well-being and survival; OR 3) providing adequate and timely COVID care will be particularly challenging as a result of your disability?
Yes
No

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