April 10 FIRST DOSE – PRIMECARE PHARMACY COVID VACCINE APPOINTMENT & CONSENT FORM

Appointment Time {appointmentTime} Have you ever received a dose of COVID-19 Vaccine? {haveYou} Are you employed in the following Critical Infrastructure Industries Social Services (DCS) (includes child welfare agency personnel with direct public exposure), Commercial agriculture, Commercial food production, Corrections staff not included in 1a1 (includes administrative staff, those without regular public/inmate contact) or {areYou83} Are you employed in the following that are critical Infrastructure Industries to the continuation of operations for certain sectors such as safety, mechanical, and engineering personnel for Transportation (including postal and package delivery) freight, railroad, maritime cargo, and commercial or cargo service airports; mechanical, and engineering personnel for courier and parcel delivery service; public infrastructure workers responsible for operation or safety of dams, locks, bridges, and roads and for solid waste collection and processing; telecommunications industry technicians and engineers involved in installation, operations and maintenance functions; and safety, production, distribution, mechanical and engineering personnel for utilities and energy sector operations, Transportation (including postal and package delivery, freight railroad, maritime cargo, commercial or cargo service airports) , Public infrastructure (includes dams, roads, locks, and bridge maintenance and engineering, solid waste collection, and processing), Telecommunications (includes those providing direct services) {areYou84} Email Address {emailAddress} Have you ever received a dose of COVID-19 Vaccine ? {ltstronggthaveYou88} Have you ever received a dose of COVID-19 Vaccine ? {ltstronggthaveYou90} List ALL the medications and/or any previously mentioned products that you are allergic to ? {ltstronggtlistAll} Have you ever received a dose of COVID-19 Vaccine ? {ltstronggthaveYou89} List ALL the medications and/or any previously mentioned products that you are allergic to ? {ltstronggtlistAll92} Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19 ? {ltstronggthaveYou86} Have you ever received a dose of COVID-19 Vaccine ? {ltstronggthaveYou88} Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19 ? {ltstronggthaveYou} Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19 ? {ltstronggthaveYou81}

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