Registration
First Name
*
Last Name
*
Email Id
*
Phone
*
Date Of Birth
*
Employee Id
*
State
*
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Company
*
-- Select Company --
51 Minds
Store
*
-- Select Store --
Have you received annual Flu Shot for year 2021?
*
Yes
No
Select Covid-19 Vaccine Status
*
Exempted
Non Vaccinated
Vaccinated
1
st
Dose From
*
Select Company Name of Vaccine
Pfizer
Moderna
Jansen
Other
1
st
Dose Date
*
Upload Vaccine Card Of 1
st
Dose
*
Have you been administered 2
nd
dose?
*
Yes
No
2
nd
Dose From
*
Select Company Name of Vaccine
Pfizer
Moderna
Jansen
Other
2
nd
Dose Date
*
Upload Vaccine Card Of 2
nd
Dose
*
Have you been administered Additional Dose/Booster?
*
Yes
No
Booster Dose From
*
Select Company Name of Booster Dose
Pfizer
Moderna
Jansen
Other
Booster Dose Date
*
Upload Vaccine Card Of Booster Dose
*