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COVID-19 Vaccination Request for Riley County Residents

2. Call 785-565-6560 if you have questions or need assistance with the form.

   Call 785-565-6560 if you have questions or need assistance with the form.

4. First Name*

5. Last Name*

7. Birth Year*

9. Phone Number (no dashes or slashes, please include area code)*

10. Does this phone number receive text messages? *

    1. Yes
    2. No

12. Home Address*

14. City*

15. County*

16. Zip*

18. Email Address*

20. Are you a K-State faculty, staff or student?*

    1. Yes
    2. No

22. Employer*

24. Employer Address*

25. City*

29. Who is your primary care physician?*

31. A verification process will be in place to ensure you are eligible due to the following medical conditions.

33. Do you have any of these conditions (cancer, chronic kidney disease, obesity, chronic obstructive pulmonary disease, down syndrome, heart conditions such as cardiomyopathies, immunocompromised state from solid organ transplant, type 2 diabetes mellitus, sickle cell disease, pregnant)*

    1. Yes
    2. No

35. Do you have any of these conditions (asthma - moderate to severe, cerebrovascular disease - affects blood vessels and blood supply to the brain, cystic fibrosis, immunocompromised state - weakened immune system from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines, neurologic conditions such as dementia, liver disease, pulmonary fibrosis - have damaged or scarred lung tissues, thalassemia - a type of blood disorder, type 1 diabetes mellitus)*

    1. Yes
    2. No

37. Are you homebound and unable to travel?*

    1. Yes
    2. No

39. Call 785-565-6560 if you have questions or need assistance with the form.

    Call 785-565-6560 if you have questions or need assistance with the form.

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41. Submit Submit and Print

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