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MONTGOMERY COUNTY DEPARTMENT OF HEALTH COVID VACCINATION

1. Contact Information
This question requires a valid email address.
2. Communication Preference
This question requires a valid date format of MM/DD/YYYY.
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This question requires a valid number format.
6. Ethnicity
7. Preferred Language
8. Insurance Coverage
9. Please attach a copy of your insurance card. 
11. Are you an essential frontline worker? (Police, Food Processing, Teacher, etc.)
12. Do you reside or work in a long-term care/assisted living facility?
13. Are you feeling sick today?
14. Have you ever received a dose of COVID-19 vaccine?
15. Which vaccine product have you received?
This question requires a valid date format of MM/DD/YYYY.
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15. Have you ever received a second dose of COVID-19 vaccine?
This question requires a valid date format of MM/DD/YYYY.
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15. Have you received a third dose or booster dose? 
This question requires a valid date format of MM/DD/YYYY.
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15. Have you received a fourth dose or booster dose? 
This question requires a valid date format of MM/DD/YYYY.
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15. Have you had a severe allergic reaction to: 
(This would include a severe allergic reaction (e.g. anaphylaxis) that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)
Space Cell YesNo
A component of COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures.
Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids.
A previous dose of COVID-19 vaccine.
16. Have you ever had an allergic reaction to another vaccine (other than COVID-19) vaccine) or an injectable medication (This would include a severe allergic reaction as stated above).