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COVID-19 Vaccine Voucher Registration [Port Isabel Businesses ONLY]

  1. PORT ISABEL BUSINESS INFO

  2. EMPLOYEE #1

  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. EMPLOYEE #2

  5. 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.

  6. EMPLOYEE #3

  7. 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.

  8. EMPLOYEE #4

  9. 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.

  10. EMPLOYEE #5

  11. 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.

  12. EMPLOYEE #6

  13. 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.

  14. EMPLOYEE #7

  15. 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.

  16. EMPLOYEE #8

  17. 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.

  18. EMPLOYEE #9

  19. 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.

  20. EMPLOYEE #10

  21. 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.

  22. Leave This Blank:

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