Date of Registration Today M-D-Y
Which vaccine(s) would you like to receive today?* must provide value
Flu
COVID-19
Which Flu shot do you need?* must provide value
Regular Flu Shot (ages 3 and up)
Adjuvanted Flu Shot (ages 65+)
Flumist Nasal Spray (ages 2-49)
Regular Flu Shot (ages 3 and up)
Adjuvanted Flu Shot (ages 65+)
Flumist Nasal Spray (ages 2-49)
Please take the time to download and read this Flu Vaccine Fact Sheet. Please take the time to download and read this Flu Vaccine Fact Sheet. Please take the time to download and read this Flu Vaccine Fact Sheet. Please take the time to download and read this Flu Vaccine Fact Sheet.
I have read the information on the influenza vaccination and wish to receive an influenza vaccination. I consent to the vaccination being given to me by a pharmacist or College of Pharmacy student under the supervision of a pharmacist, a nurse or student nurse under the supervision of nurse, or other qualified healthcare professional. I have read the information for Inactivated Influenza Vaccine and understand the risks and benefits of the Influenza Vaccine.
I hereby authorize OU College of Pharmacy to furnish to my insurance carrier(s) information concerning this vaccination and related documentation and assign to the College of Pharmacy all payments for the vaccination and services rendered to me.
I have had an opportunity to ask questions, all of which have been answered to my satisfaction, and I hereby waive any and all claims for damages arising out of or related to this vaccination that I (or anyone claiming on my behalf) may have against the Board of Regents of the University of Oklahoma, including, but not limited to, its Regents, employees, officers, directors, the OU College of Pharmacy, administering staff, pharmacists, student pharmacists, nurses, and student nurses. I understand that it is strongly recommended that I wait in the vaccination area for 15 minutes after administration of the vaccine for observation for possible related reactions.
Signature of patient to receive Influenza Vaccine (or parent, guardian, or authorized representative)
Please click on the green "add signature" link above to add your signature.
If your device does not allow you to submit a signature, please indicate your consent by entering your intials in the box above.
By signing on behalf of the patient, you are stating that you are authorized to provide the required representations on behalf of the patient.
Date
Flu signature
Initials
Flu date Today M-D-Y
I understand that the College of Pharmacy maintains a list of individuals receiving a flu vaccination. If I am a student, trainee, volunteer, or employee of the University of Oklahoma Health Sciences Center or OU Medicine, Inc. (“OUMI”) (collectively “OU Health”), I authorize the College of Pharmacy to release written confirmation that I received a flu shot, as well as the date of such service, to OU, OUMI, the VA Medical Center, and other health care entities requiring confirmation of my flu immunization prior to permitting me to be a trainee or to provide services that require access to their patients or facilities. I understand that if I am also a current patient of OU Health, documentation of this vaccination will be included in my OU Health medical records. Finally, I understand that:
I may revoke this Authorization to share this immunization information at any time, in writing, to the College of Pharmacy (COP) or University Privacy Official at Box 26901, OKC, OK 73119. My revocation will not apply to information already retained, used, or disclosed under this Authorization. Unless sooner revoked, the automatic expiration date will be sixty (60) months from the date of signature. The COP may not condition the provision of treatment or payment for my care on my signing this Authorization. Information used or disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations. The information authorized for release may include information that may indicate the presence of a communicable or non-communicable disease. The information authorized for release also may include protected health information related to mental health. The information authorized for release may include substance use disorder records. This category of medical information/records is protected by Federal confidentiality rules (42 CFR Part 2). A general authorization for the release of medical or other information is not sufficient for this purpose. As a result, by signing below, I specifically authorize any such records included in my health information to be released. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. The Federal rules prohibit anyone receiving this information or record from making further release unless further release is expressly permitted by the written authorization of the person to whom it pertains or is otherwise permitted by 42 CFR Part 2.
Signature of patient to receive Influenza Vaccine (or parent, guardian, or authorized representative)
Please click on the green "add signature" link above to add your signature.
If your device does not allow you to submit a signature, please indicate your consent by entering your intials in the box above.
By signing on behalf of the patient, you are stating that you are authorized to provide the required representations on behalf of the patient.
Date
signature
initials
date Today M-D-Y
Are you currently experiencing fever, chills, cough, shortness of breath, fatigue, muscle aches, headache, nausea, vomiting, diarrhea, congestion, runny nose, or new loss of taste or smell?
I have read the information on the influenza vaccination and wish to receive a FluMist influenza vaccination. I consent to the vaccination being given to me by a pharmacist or College of Pharmacy student under the supervision of a pharmacist, a nurse or student nurse under the supervision of nurse, or other qualified healthcare professional. I have read the information for Live, Attenuated Flu Vaccine and understand the risks and benefits of the Influenza Vaccine.
Signature of patient to receive Influenza Intranasal Vaccine (or parent, guardian, or authorized representative)
Please click on the green "add signature" link above to add your signature.
If your device does not allow you to submit a signature, please indicate your consent by entering your intials in the box above.
By signing on behalf of the patient, you are stating that you are authorized to provide the required representations on behalf of the patient.
Date
Flumist signature
Initials
Flumist date Today M-D-Y
I understand that the College of Pharmacy maintains a list of individuals receiving a flu vaccination. If I am a student, trainee, volunteer, or employee of the University of Oklahoma Health Sciences Center or OU Medicine, Inc. ("OUMI") (collectively "OU Health"), I authorize the College of Pharmacy to release written confirmation that I received a flu shot, as well as the date of such service, to OU, OUMI, the VA Medical Center, and other health care entities requiring confirmation of my flu immunization prior to permitting me to be a trainee or to provide services that require access to their patients or facilities. I understand that if I am also a current patient of OU Health, documentation of this vaccination will be included in my OU Health medical records. Finally, I understand that:
I may revoke this Authorization to share this immunization information at any time, in writing, to the College of Pharmacy (COP) or University Privacy Official at Box 26901, OKC, OK 73119. My revocation will not apply to information already retained, used, or disclosed under this Authorization. Unless sooner revoked, the automatic expiration date will be sixty (60) months from the date of signature. The COP may not condition the provision of treatment or payment for my care on my signing this Authorization. Information used or disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations. The information authorized for release may include information that may indicate the presence of a communicable or non-communicable disease. The information authorized for release also may include protected health information related to mental health. The information authorized for release may include substance use disorder records. This category of medical information/records is protected by Federal confidentiality rules (42 CFR Part 2). A general authorization for the release of medical or other information is not sufficient for this purpose. As a result, by signing below, I specifically authorize any such records included in my health information to be released. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. The Federal rules prohibit anyone receiving this information or record from making further release unless further release is expressly permitted by the written authorization of the person to whom it pertains or is otherwise permitted by 42 CFR Part 2.
Signature of patient to receive Influenza Intranasal Vaccine (or parent, guardian, or authorized representative)
Please click on the green "add signature" link above to add your signature.
If your device does not allow you to submit a signature, please indicate your consent by entering your intials in the box above.
By signing on behalf of the patient, you are stating that you are authorized to provide the required representations on behalf of the patient.
Date
signature
initials
date Today M-D-Y
Have you received a dose of the COVID-19 vaccine before? Yes
No
Which vaccine product did you receive? Pfizer
Moderna
Johnson & Johnson
Other:
Pfizer
Moderna
Johnson & Johnson
Other:
Other covid shot
If mRNA (Pfizer or Moderna) COVID-19 vaccine previously received, I attest that I am eligible for another dose of the same COVID-19 vaccine brand based on the following criteria: * must provide value
3 or more weeks since dose 1 of Pfizer or 4 or more weeks since dose 1 of Moderna
4 or more weeks since dose 2 of Pfizer or Moderna and immunocompromised (i.e. cancer, transplant, HIV infection, high-dose corticosteroids or other immunosuppressant medication)
5 or more months since dose 2 of Pfizer or Moderna or 2 or more months after a Johnson & Johnson vaccine and after the primary series for individuals 16 years and older
50+ and/or immunocompromised and 4 or more months since previous booster dose.
None of the above
3 or more weeks since dose 1 of Pfizer or 4 or more weeks since dose 1 of Moderna
4 or more weeks since dose 2 of Pfizer or Moderna and immunocompromised (i.e. cancer, transplant, HIV infection, high-dose corticosteroids or other immunosuppressant medication)
5 or more months since dose 2 of Pfizer or Moderna or 2 or more months after a Johnson & Johnson vaccine and after the primary series for individuals 16 years and older
50+ and/or immunocompromised and 4 or more months since previous booster dose.
None of the above
Do you currently have an acute illness with or without fever?* must provide value
Yes
No
If yes, have you completed the OU Employee and Student COVID screening and reporting tool at https://covidreporting.ouhsc.edu/ for any symptoms consistent with COVID-19 including fever, cough, and congestion and am cleared to be on campus? * must provide value
Yes
No
Non-applicable as I don't have any COVID specific symptoms or I am not an employee of student of OUHSC or OU Health
Yes
No
Non-applicable as I don't have any COVID specific symptoms or I am not an employee of student of OUHSC or OU Health
You cannot come to the vaccine clinic until you have completed the screening tool and are cleared. Please take the time to download and read this Pfizer-BioNTech COVID-19 Vaccine EUA Fact Sheet. Please take the time to download and read this Pfizer-BioNTech COVID-19 Vaccine EUA Fact Sheet for Patients ages 5-11 years. Please take the time to download and read this Moderna COVID-19 Vaccine EUA Fact Sheet. Please take the time to download and read this Janssen COVID-19 Vaccine EUA Fact Sheet. Espanol Pfizer-BioNTech Espanol Moderna
I certify that my answers and the information contained in my responses are all true, correct, and complete to the best of my knowledge and that I have withheld nothing, which, if disclosed, would cause me to not be eligible for the vaccine (even a booster dose) or possibly have a different impact on my eligibility or screening for the vaccine (even a booster dose). * must provide value
I certify.
Are you pregnant or breastfeeding? (Note: The Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists (ACOG) recommend COVID vaccination in pregnant, breast feeding, and childbearing age women.)* must provide value
Yes
No
Unsure
SERVICES REQUEST AND AUTHORIZATION:
I understand the benefits and risks of the COVID‐19 Vaccination, and I voluntarily assume all risks and take full responsibility for any reactions that may result. I understand I should remain in the vaccine administration area for 15‐30 minutes after the vaccination to be monitored for any potential adverse reactions. I understand if I experience side effects that I should, as appropriate: contact a doctor, call the vaccine provider or call 911if it is an emergency. I hereby waive any and all claims for damages arising out of or related to this vaccination that I (or anyone claiming on my behalf) may have against OU Medicine, Inc. (“OUMI”) and/or the Board of Regents of the University of Oklahoma (the
AUTHORIZATION TO REQUEST MEDICARE, MEDICAID, or HRSA REIMBURSEMENT:
In the event I do not have private insurance, I authorize the University or OUMI, as applicable, to release information and request reimbursement for administration of this vaccine. I certify that the information given by me for applying for reimbursement by Medicare, Medicaid, or HRSA COVID-19 Program for Uninsured Patients is correct. I authorize the release of all records necessary for reimbursement. I request that payment of authorized benefits be made on my behalf.
DISCLOSURE OF RECORDS:
I understand that a record of my immunization will be maintained and the provider, University or OUMI, may be required to or may voluntarily disclose my health information to a physician, health care professional, hospital, clinic , laboratory, pharmacy, medical facility, my insurance plan, and/or state or federal registries, for purposes of treatment, payment, or other health care operations. I also understand that that my health information may be used and disclosed as set forth in the Notice of Privacy Practices maintained by each entity and copies are available as follows:
University: https://apps.ouhsc.edu/hipaa/hpp.asp or contact OU Office of compliance - (405) 271-2511; Anonymous OU Compliance Hotline - (405) 271-2223 / (866) 836-3150. OUMI: https://www.ouhealth.com/ou-health-patients-families/notice-of-privacy-practices/ or contact Amber Simpson, Facility Privacy Official - (405) 271-5920; email - privacy@oumedicine.com . LIMITED DICLOSURE AUTHORIZATION. if I am en employee or volunteer of the University or OUMI or a student or trainee of the University, I authorize the provider herein to release written confirmation of my COVID-19 Vaccine dose number and date of service, provided such disclosure is limited to OUMI, the University, and those health care entitties requiring confirmation of my vaccination for employment, training, access, or performance purposes. I understand that:
I may revoke this Authorization to disclose this immunization information at any time, in writing, to the University Privacy Official at Box 26901, OKC, OK 73119 and OU Medicine, Inc., Facility Privacy Official at 700 NE 13th Street, Oklahoma City, OK 73104. My revocation will not apply to information already retained, used, or disclosed under this Authorization. Unless sooner revoked, the automatic expiration date will be one (1) year from the date of signature below. The provider may not condition the provision of services, treatment, or payment for my care on my signing this Authorization. Information used or disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations.
Signature of patient to receive COVID-19 Vaccine (or parent, guardian, or authorized representative)
Please click on the green "add signature" link above to add your signature.
If your device does not allow you to submit a signature, please indicate your consent by entering your intials in the box above.
By signing on behalf of the patient, you are stating that you are authorized to provide the required representations on behalf of the patient.
Date
First Name Last Name Relationship: Phone:
Parent, guardian, or authorized representative
Signature
Initials
Today's Date (MM-DD-YYYY)* must provide value
Today M-D-Y
first Name
last Name
Relationship to patient
Guardian Phone Number
other
Age (years) View equation
Please indicate the status of the person who will be receiving the vaccine* must provide value
UNIVERSITY Employee (OUHSC)
Student (OUHSC)
HOSPITAL/OU Health Employee
UHAT
Other:
UNIVERSITY Employee (OUHSC)
Student (OUHSC)
HOSPITAL/OU Health Employee
UHAT
Other:
Please enter your HR number. * must provide value
Please enter your 3-4 ID Number (3 letters followed by 4 numbers)* must provide value
Last Name* must provide value
First Name* must provide value
Middle name
Date of Birth (MM-DD-YYYY)* must provide value
M-D-Y
Gender* must provide value
Male Female
Address Line 1* must provide value
Address Line 2
City * must provide value
Achille Ada Adair Addington Afton Agra Akins Albany Albion Alderson Alex Aline Allen Altus Alva Amber Ames Amorita Anadarko Antlers Apache Arapaho Arcadia Ardmore Arkoma Armstrong Arnett Arpelar Asher Ashland Atoka Atwood Avant Badger Lee Ballou Barnsdall Bartlesville Bearden Beaver Bee Beggs Belfonte Bell Bennington Bernice Bessie Bethany Bethel Acres Big Cabin Billings Binger Bison Bixby Blackburn Blackgum Blackwell Blair Blanchard Blanco Blue Bluejacket Boise City Bokchito Bokoshe Boley Boswell Bowlegs Box Boynton Bradley Braggs Braman Bray Breckenridge Brent Bridge Creek Bridgeport Briggs Bristow Broken Arrow Broken Bow Bromide Brooksville Brush Creek Brushy Buffalo Bull Hollow Burbank Burlington Burneyville Burns Flat Bushyhead Butler Byars Byng Byron Cache Caddo Calera Calumet Calvin Camargo Cameron Canadian Caney Canton Canute Carlisle Carmen Carnegie Carney Carrier Carter Cartwright Cashion Castle Catoosa Cayuga Cedar Crest Cedar Valley Cement Centrahoma Central High Chandler Chattanooga Checotah Chelsea Cherokee Cherry Tree Chester Chewey Cheyenne Chickasha Choctaw Chouteau Christie Cimarron City Claremore Clarita Clayton Clearview Cleo Springs Cleora Cleveland Clinton Cloud Creek Coalgate Colbert Colcord Cole Coleman Collinsville Colony Comanche Commerce Connerville Cooperton Copan Copeland Corn Cornish Council Hill Covington Coweta Cowlington Coyle Crescent Cromwell Crowder Cushing Custer City Cyril Dacoma Dale Davenport Davidson Davis Deer Creek Deer Lick Del City Delaware Dennis Depew Devol Dewar Dewey Dibble Dickson Dill City Disney Dodge Dotyville Dougherty Douglas Dover Dripping Springs Drowning Creek Drummond Drumright Dry Creek Duchess Landing Duncan Durant Dustin Dwight Mission Eagletown Eakly Earlsboro East Duke Edmond El Reno Eldon Eldorado Elgin Elk City Elm Grove Elmer Elmore City Empire City Enid Erick Erin Springs Etowah Eufaula Evening Shade Fair Oaks Fairfax Fairfield Fairland Fairmont Fairview Fallis Fanshawe Fargo Faxon Felt Fitzhugh Fletcher Flint Creek Flute Springs Foraker Forest Park Forgan Fort Cobb Fort Coffee Fort Gibson Fort Supply Fort Towson Foss Foster Foyil Francis Frederick Freedom Friendship Gage Gans Garber Garvin Gate Geary Gene Autry Geronimo Gerty Gideon Glencoe Glenpool Goldsby Goltry Goodwell Gore Gotebo Gould Gowen Gracemont Grainola Grand Lake Towne Grandfield Grandview Granite Grant Grayson Greasy Greenfield Gregory Grove Guthrie Guymon Haileyville Hallett Hammon Hanna Hardesty Harrah Hartshorne Haskell Hastings Haworth Headrick Healdton Heavener Helena Hendrix Hennessey Henryetta Hickory Hillsdale Hinton Hitchcock Hitchita Hobart Hoffman Holdenville Hollis Hollister Hominy Hooker Hoot Owl Horntown Howe Hugo Hulbert Hunter Hydro Idabel Indiahoma Indianola Inola Iron Post Isabella IXL Jay Jefferson Jenks Jennings Jet Johnson Jones Justice Kansas Katie Kaw City Kellyville Kemp Kendrick Kenefic Kenton Kenwood Keota Ketchum Keyes Keys Kiefer Kildare Kingfisher Kingston Kinta Kiowa Knowles Konawa Krebs Kremlin Lahoma Lake Aluma Lamar Lambert Lamont Lane Langley Langston Latta Laverne Lawrence Creek Lawton Le Flore Leach Lebanon Leedey Lehigh Lenapah Leon Lequire Lexington Liberty Lima Limestone Lindsay Loco Locust Grove Lone Grove Lone Wolf Long Longdale Longtown Lookeba Lost City Lotsee Loveland Loyal Lucien Luther Lyons Switch Macomb Madill Manchester Mangum Manitou Mannford Mannsville Maramec Marble City Marietta Marland Marlow Marshall Martha Maud May Maysville Mazie McAlester McCord McCurtain McLoud Mead Medford Medicine Park Meeker Meno Meridian Miami Midwest City Milburn Mill Creek Millerton Minco Moffett Monroe Moore Mooreland Morris Morrison Mounds Mountain Park Mountain View Mulberry Muldrow Mulhall Murphy Muskogee Mustang Mutual Narcissa Nardin Nash Nescatunga New Alluwe New Cordell New Eucha New Woodville Newcastle Newkirk Nichols Hills Nicoma Park Nicut Ninnekah Noble Norge Norman North Enid North Miami Notchietown Nowata Oak Grove Oakhurst Oakland Oaks Oakwood Ochelata Oilton Okarche Okay Okeene Okemah Oklahoma City Okmulgee Oktaha Old Eucha Old Green Olustee Oologah Optima Orlando Osage Owasso Paden Panama Panola Paoli Paradise Hill Park Hill Pauls Valley Pawhuska Pawnee Peavine Peggs Pensacola Peoria Perkins Perry Pettit Phillips Piedmont Pin Oak Acres Piney Pinhook Corner Pink Pittsburg Platter Pocasset Pocola Ponca City Pond Creek Porter Porum Poteau Prague Proctor Prue Pryor Creek Pump Back Purcell Putnam Quapaw Quinton Ralston Ramona Randlett Ratliff City Rattan Ravia Red Oak Red Rock Redbird Redbird Smith Remy Renfrow Rentiesville Reydon Ringling Ringwood Ripley River Bottom Rock Island Rocky Rocky Ford Rocky Mountain Roff Roland Roosevelt Rose Rosedale Rosston Rush Springs Ryan Salina Sallisaw Sand Hill Sand Springs Sapulpa Sasakwa Savanna Sawyer Sayre Schulter Scraper Seiling Seminole Sentinel Sequoyah Shady Grove Shady Point Shamrock Sharon Shattuck Shawnee Shidler Short Silo Simms Skedee Skiatook Slaughterville Slick Smith Village Smithville Snake Creek Snyder Soper Sour John South Coffeyville Sparks Spaulding Spavinaw Spencer Sperry Spiro Sportsmen Acres Springer St. Louis Steely Hollow Sterling Stidham Stigler Stillwater Stilwell Stonewall Stoney Point Strang Stratford Stringtown Strong City Stroud Stuart Sugden Sulphur Summit Sweetwater Swink Sycamore Taft Tahlequah Talala Talihina Taloga Tamaha Tatums Tecumseh Temple Tenkiller Teresita Terlton Terral Texanna Texhoma Texola Thackerville The Village Thomas Tiawah Tipton Tishomingo Titanic Tonkawa Tribbey Tryon Tullahassee Tulsa Tupelo Turley Turpin Tushka Tuskahoma Tuttle Twin Oaks Tyrone Union City Valley Brook Valley Park Valliant Velma Vera Verden Verdigris Vian Vici Vinita Wagoner Wainwright Wakita Walters Wanette Wann Wapanucka Wardville Warner Warr Acres Warwick Washington Watonga Watts Wauhillau Waukomis Waurika Wayne Waynoka Weatherford Webb City Webbers Falls Welch Weleetka Welling Wellston West Peavine West Siloam Springs Westport Westville Wetumka Wewoka White Oak White Water Whitefield Whitesboro Wickliffe Wilburton Willow Wilson Winchester Wister Woodall Woodlawn Park Woodward Wright City Wyandotte Wynnewood Wynona Yale Yeager Yukon Zeb Zena Zion
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AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
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Verify your Email Address* must provide value
* must provide value
Health Insurance Card
Please take a photo of you insurance card with your phone and then upload it to this box
The insurance card is being collected to request insurance reimbursement for vaccine administration
You will not incur any charges for this vaccination.
Your e-mail addresses do not match. Please re-enter Race* must provide value
American Indian or Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Black or African American
White
Other Race
Prefer not to answer
American Indian or Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Black or African American
White
Other Race
Prefer not to answer
Ethnicity* must provide value
Hispanic
Not Hispanic or Latino
Unknown
Prefer not to answer
Hispanic
Not Hispanic or Latino
Unknown
Prefer not to answer
First Name
Last Name
Phone Number
Relationship
Address Line 1
Address Line 2
City Achille Ada Adair Addington Afton Agra Akins Albany Albion Alderson Alex Aline Allen Altus Alva Amber Ames Amorita Anadarko Antlers Apache Arapaho Arcadia Ardmore Arkoma Armstrong Arnett Arpelar Asher Ashland Atoka Atwood Avant Badger Lee Ballou Barnsdall Bartlesville Bearden Beaver Bee Beggs Belfonte Bell Bennington Bernice Bessie Bethany Bethel Acres Big Cabin Billings Binger Bison Bixby Blackburn Blackgum Blackwell Blair Blanchard Blanco Blue Bluejacket Boise City Bokchito Bokoshe Boley Boswell Bowlegs Box Boynton Bradley Braggs Braman Bray Breckenridge Brent Bridge Creek Bridgeport Briggs Bristow Broken Arrow Broken Bow Bromide Brooksville Brush Creek Brushy Buffalo Bull Hollow Burbank Burlington Burneyville Burns Flat Bushyhead Butler Byars Byng Byron Cache Caddo Calera Calumet Calvin Camargo Cameron Canadian Caney Canton Canute Carlisle Carmen Carnegie Carney Carrier Carter Cartwright Cashion Castle Catoosa Cayuga Cedar Crest Cedar Valley Cement Centrahoma Central High Chandler Chattanooga Checotah Chelsea Cherokee Cherry Tree Chester Chewey Cheyenne Chickasha Choctaw Chouteau Christie Cimarron City Claremore Clarita Clayton Clearview Cleo Springs Cleora Cleveland Clinton Cloud Creek Coalgate Colbert Colcord Cole Coleman Collinsville Colony Comanche Commerce Connerville Cooperton Copan Copeland Corn Cornish Council Hill Covington Coweta Cowlington Coyle Crescent Cromwell Crowder Cushing Custer City Cyril Dacoma Dale Davenport Davidson Davis Deer Creek Deer Lick Del City Delaware Dennis Depew Devol Dewar Dewey Dibble Dickson Dill City Disney Dodge Dotyville Dougherty Douglas Dover Dripping Springs Drowning Creek Drummond Drumright Dry Creek Duchess Landing Duncan Durant Dustin Dwight Mission Eagletown Eakly Earlsboro East Duke Edmond El Reno Eldon Eldorado Elgin Elk City Elm Grove Elmer Elmore City Empire City Enid Erick Erin Springs Etowah Eufaula Evening Shade Fair Oaks Fairfax Fairfield Fairland Fairmont Fairview Fallis Fanshawe Fargo Faxon Felt Fitzhugh Fletcher Flint Creek Flute Springs Foraker Forest Park Forgan Fort Cobb Fort Coffee Fort Gibson Fort Supply Fort Towson Foss Foster Foyil Francis Frederick Freedom Friendship Gage Gans Garber Garvin Gate Geary Gene Autry Geronimo Gerty Gideon Glencoe Glenpool Goldsby Goltry Goodwell Gore Gotebo Gould Gowen Gracemont Grainola Grand Lake Towne Grandfield Grandview Granite Grant Grayson Greasy Greenfield Gregory Grove Guthrie Guymon Haileyville Hallett Hammon Hanna Hardesty Harrah Hartshorne Haskell Hastings Haworth Headrick Healdton Heavener Helena Hendrix Hennessey Henryetta Hickory Hillsdale Hinton Hitchcock Hitchita Hobart Hoffman Holdenville Hollis Hollister Hominy Hooker Hoot Owl Horntown Howe Hugo Hulbert Hunter Hydro Idabel Indiahoma Indianola Inola Iron Post Isabella IXL Jay Jefferson Jenks Jennings Jet Johnson Jones Justice Kansas Katie Kaw City Kellyville Kemp Kendrick Kenefic Kenton Kenwood Keota Ketchum Keyes Keys Kiefer Kildare Kingfisher Kingston Kinta Kiowa Knowles Konawa Krebs Kremlin Lahoma Lake Aluma Lamar Lambert Lamont Lane Langley Langston Latta Laverne Lawrence Creek Lawton Le Flore Leach Lebanon Leedey Lehigh Lenapah Leon Lequire Lexington Liberty Lima Limestone Lindsay Loco Locust Grove Lone Grove Lone Wolf Long Longdale Longtown Lookeba Lost City Lotsee Loveland Loyal Lucien Luther Lyons Switch Macomb Madill Manchester Mangum Manitou Mannford Mannsville Maramec Marble City Marietta Marland Marlow Marshall Martha Maud May Maysville Mazie McAlester McCord McCurtain McLoud Mead Medford Medicine Park Meeker Meno Meridian Miami Midwest City Milburn Mill Creek Millerton Minco Moffett Monroe Moore Mooreland Morris Morrison Mounds Mountain Park Mountain View Mulberry Muldrow Mulhall Murphy Muskogee Mustang Mutual Narcissa Nardin Nash Nescatunga New Alluwe New Cordell New Eucha New Woodville Newcastle Newkirk Nichols Hills Nicoma Park Nicut Ninnekah Noble Norge Norman North Enid North Miami Notchietown Nowata Oak Grove Oakhurst Oakland Oaks Oakwood Ochelata Oilton Okarche Okay Okeene Okemah Oklahoma City Okmulgee Oktaha Old Eucha Old Green Olustee Oologah Optima Orlando Osage Owasso Paden Panama Panola Paoli Paradise Hill Park Hill Pauls Valley Pawhuska Pawnee Peavine Peggs Pensacola Peoria Perkins Perry Pettit Phillips Piedmont Pin Oak Acres Piney Pinhook Corner Pink Pittsburg Platter Pocasset Pocola Ponca City Pond Creek Porter Porum Poteau Prague Proctor Prue Pryor Creek Pump Back Purcell Putnam Quapaw Quinton Ralston Ramona Randlett Ratliff City Rattan Ravia Red Oak Red Rock Redbird Redbird Smith Remy Renfrow Rentiesville Reydon Ringling Ringwood Ripley River Bottom Rock Island Rocky Rocky Ford Rocky Mountain Roff Roland Roosevelt Rose Rosedale Rosston Rush Springs Ryan Salina Sallisaw Sand Hill Sand Springs Sapulpa Sasakwa Savanna Sawyer Sayre Schulter Scraper Seiling Seminole Sentinel Sequoyah Shady Grove Shady Point Shamrock Sharon Shattuck Shawnee Shidler Short Silo Simms Skedee Skiatook Slaughterville Slick Smith Village Smithville Snake Creek Snyder Soper Sour John South Coffeyville Sparks Spaulding Spavinaw Spencer Sperry Spiro Sportsmen Acres Springer St. Louis Steely Hollow Sterling Stidham Stigler Stillwater Stilwell Stonewall Stoney Point Strang Stratford Stringtown Strong City Stroud Stuart Sugden Sulphur Summit Sweetwater Swink Sycamore Taft Tahlequah Talala Talihina Taloga Tamaha Tatums Tecumseh Temple Tenkiller Teresita Terlton Terral Texanna Texhoma Texola Thackerville The Village Thomas Tiawah Tipton Tishomingo Titanic Tonkawa Tribbey Tryon Tullahassee Tulsa Tupelo Turley Turpin Tushka Tuskahoma Tuttle Twin Oaks Tyrone Union City Valley Brook Valley Park Valliant Velma Vera Verden Verdigris Vian Vici Vinita Wagoner Wainwright Wakita Walters Wanette Wann Wapanucka Wardville Warner Warr Acres Warwick Washington Watonga Watts Wauhillau Waukomis Waurika Wayne Waynoka Weatherford Webb City Webbers Falls Welch Weleetka Welling Wellston West Peavine West Siloam Springs Westport Westville Wetumka Wewoka White Oak White Water Whitefield Whitesboro Wickliffe Wilburton Willow Wilson Winchester Wister Woodall Woodlawn Park Woodward Wright City Wyandotte Wynnewood Wynona Yale Yeager Yukon Zeb Zena Zion
State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
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Above you indicated receiving passive antibodies (e.g. monoclonal antibodies or convalescent plasma) as part of COVID-19 treatment within the past 90 days.
It is recommended that you delay vaccine by 90 days after passive antibody therapy. Unless you keyed in the wrong response above, please end your survey now.
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