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COVID-19 Vaccine Voucher Registration

  1. Are you able to travel to the location of the COVID-19 vaccine??*

    The Vaccine location will be announced when you are contacted with your voucher.

  2. Have you received your first dose?*

  3. Do you have any of the following conditions?*

    Lung Disease, Heart Disease, Asthma, Kidney Disease, Diabetes, Obesity/Severe Obesity, Pregnancy, Smoker, Down Syndrome, Hypertension, Neurological Disorder, Stroke, Other.

  4. I acknowledge the following:*

    -that the information I have entered on this form is correct.

    -that completion of this form does not guarantee a voucher, and that I should continue to seek a vaccination from other providers.

    -that if I have a medical condition, I have consulted with my physician regarding the suitability of the COVID-19 vaccine.

    -that the City of Port Isabel is not a medical provider, and that no patient relationship is created between the city or its agents and me.

    -that the City of Port Isabel is not liable for any claim arising from the delivery of a vaccination by a third party, including the failure of a third party to deliver a vaccination.

    Reconozco lo siguiente:

    -que la información que he introducido en este formulario es correcta.

    -que la cumplimentación de este formulario no garantiza un boleto, y que debo seguir buscando una vacuna de otros proveedores.

    -que si tengo una condición médica, he consultado con mi médico sobre la idoneidad de la vacuna COVID-19.

    -que la Ciudad de Port Isabel no es un proveedor médico, y que no se crea ninguna relación de pacientes entre la ciudad o sus agentes y yo.

    -que la Ciudad de Port Isabel no se hace responsable de ninguna reclamación derivada de la entrega de una vacunación por parte de un tercero, incluida la falta de vacunación de un tercero.

  5. Leave This Blank:

  6. This field is not part of the form submission.