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Cornerstone Care COVID-19 Vaccine - Burgettstown

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County of Residence*
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Phone Type*
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Do you certify that you are at least 18 years old?*
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Gender*
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Marital Status*
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Race*
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Cultural Origin*
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Language Barrier*
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Homeless Status:*
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Migrant Worker Status:*
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Public Housing*
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Veteran Status*
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Are you a current Cornerstone Care Patient?*
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Are you sick today?*
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Have you been diagnosed with COVID-19 within the past 3 months by PCR or antigen testing or are you currently awaiting the results of a COVID test?*
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In the past two weeks, have you had contact with anyone who tested positive for COVID-19?*
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In the last 10 days, have you had a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea?*
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Have you had a severe reaction (such as hives or difficulty breathing) to any previous vaccine?*
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Do you have severe allergies to any medications, food, insect bites or a previous history of anaphylactic reaction or have you peen prescribed an EpiPen for any reason?*
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Are you actively being treated for any immunocompromising diseases such as cancer, lupus, rheumatoid arthritis or any other autoimmune disease?*
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For women, are you pregnant, is there a chance you could become pregnant within the next two months after this vaccine dose, or are you breastfeeding?*
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Do you certify that you have answered all screening questions accurately and to the best of your ability?*
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The Moderna Vaccine comes in 10-dose vials, so we are scheduling vaccine appointments in batches of 10. Are you interested in being added to a "Standby" list for the location selected above, so that if we have a no-show, we can call you to come in within 60 minutes to receive a vaccine so it does not go to waste?*
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Would you like to be added to the standby list for additional locations?*
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