Verification Form

In order to be eligible to receive the vaccine you have to meet the criteria established by the US Centers for Disease Control (CDC) as being “EXTREMELY VULNERABLE” from the virus that causes COVID-19.

The CDC defines “extremely vulnerable” as:

  • People with chronic lung disease or moderate to severe asthma.
  • People who have serious heart conditions.
  • People who are immunocompromised including cancer treatment.
  • People of any age with severe obesity (BMI >40) or certain underlying medical conditions, particularly if not well controlled, such as those with diabetes, renal failure, or liver disease might also be at risk.
  • Chronic kidney disease
  • Down Syndrome
  • Sickle Cell disease
  • Diabetes
  • Have been classified as clinically extremely vulnerable based on clinical judgement and assessment by the clinician.

If you think you will be eligible, please have your primary care physician fill out the form below.


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