DHC Patients who have vaccines

Please tell us if you've gotten the COVID-19 Vaccine:

Please fill in the information below

1. First Name: *This question is required.

2. Last Name: *This question is required.

3. Date of Birth: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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4. Which statement best describes your current COVID-19 vaccine status? *This question is required.

5. If you have received the vaccine (first dose or both), which brand did you get?

6. Date of your first vaccination, if applicable: This question requires a valid date format of MM/DD/YYYY.

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7. Date of your second vaccination, if applicable: This question requires a valid date format of MM/DD/YYYY.

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8. If you have not been able to schedule your vaccine appointment, tell us why: