1. I have watched the COVID-19 Vaccine Wait List video, or I have read the transcript.
2. I understand that my information will be added to a marketing and contact database, not a HIPAA compliant medical database. This wait list form is not added to my medical record.
3. I understand that my information will likely be shared with other Texas Certified COVID-19 Vaccine Providers in Matagorda County and possibly surrounding counties. If my information is shared with other providers, I will still remain on the original list and will not need to sign up again.
4. I understand that multiple signups will have a negative impact on my position in the list. Signing up a second time is just like getting out of line and coming back later when the line is longer. If I sign up a second time, my initial signup will be deleted, and I will lose my original place in line on the wait list.
5. I understand that signing up guarantees me a place on the list but does not guarantee that I will receive a vaccination.
6. I understand that I should take the first available vaccine dose from any qualified healthcare provider and that I should not turn down a vaccine opportunity because of this list.
7. I understand that there are multiple phases of COVID-19 vaccine distribution, and that during certain phases, higher risk patients may be prioritized above me. I also understand that when the general public vaccination phase begins, I will be contacted in the order I signed up.
8. I understand that the Matagorda County Hospital District is not set up to field a high volume of calls concerning the vaccine. Replies to emails and voicemails regarding the vaccine are not guaranteed to be returned before I have been vaccinated.
9. I understand that the COVID-19 vaccine is administered free of charge and that I do not have to have a medical provider’s order to receive the vaccine. However, I am aware that if I have certain medical conditions and seek the opinion of my medical provider, my medical provider may choose to require a standard office visit charge for the consultation.