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January 25, 2021

Bismarck-Burleigh Public Health COVID-19 Vaccine Eligibility Form

This form will help you identify what COVID-19 vaccine priority group you fit into. THIS IS NOT REGISTRATION FOR A COVID-19 VACCINE APPOINTMENT. Completing this form puts your name on a list for staff to contact you with appointment information when your priority group is eligible for vaccine.

If you do not have an email address, please note that in the comments section and we will call you. Email address will be used for future registration, appointment confirmations and reminders.

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