Monkeypox Vaccine Cancellation Waitlist

1. HIPAA Privacy Practices Notice and Acknowledgement

PHMDC is covered by the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is a set of federal requirements to ensure the privacy and security of an individual’s protected health information. You can find PHMDC’s Notice of Privacy Practices here: https://publichealthmdc.com/about/hipaa-open-records This Notice provides information about how we may use and disclose your protected health information and how you can get access to this information.

PHMDC's Notice of Privacy Practices *This question is required.

I acknowledge that I have received PHMDC's Notice of Privacy Practices

If this acknowledgement is completed on behalf of the individual or a minor child, please check one of the following:

Parent/Guardian
Authorized Agent

Relationship to client/minor child:

2. Monkeypox Vaccine Eligibility Self-Authentication

Please read through the categories below. If you do not belong to at least one of these categories, you are not currently eligible for monkeypox vaccine and we cannot provide vaccine to you at this time.

Which of the below categories make you eligible to receive monkeypox vaccine? *This question is required.

1 - Known contacts who are identified by public health via case investigation, contact tracing, and risk exposure assessments
2 - People who know that a sexual partner in the past 14 days was diagnosed with monkeypox
3 - People who attended an event or venue where there was known monkeypox exposure
4 - Clinical and research lab staff who directly handle orthopox viruses
5 - Healthcare providers who directly care for patients with sexually transmitted infections
6 - Gay men, bisexual men, trans men and women, any men who have sex with men, and gender non-conforming/non-binary individuals, who have had multiple sexual partners in the last 14 days
7 - Gay men, bisexual men, trans men and women, any men who have sex with men, and gender non-conforming/non-binary individuals, who expect to have multiple or anonymous sex partners

3. What is the date of your last qualifying event (confirmed or potential exposure, contact with multiple sexual partners)? *This question is required. This question requires a valid date format of MM/DD/YYYY.

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The following questions will allow us to contact you if an appointment becomes available. Please ensure that you have access to the phone and email you provide below.

3. What is your name? *This question is required.

	First name
	Last name

4. What is your date of birth? (MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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5. What is your phone number? *This question is required.

6. What is your email address?
Please provide an email address where you are comfortable receiving information about Monkeypox vaccination. *This question is required. This question requires a valid email address.

7. In the future, we may be able to connect you with providers who are also able to vaccinate. If you have health insurance, we need to know your provider in order to connect you. If you have health insurance, who is your provider?