Elders Covid19 Vaccine Interest Survey

Elders Covid19 Vaccine Interest Survey


https://app.smartsheet.com/b/form/f9498dfaac7848d1a17bc05e94944048

Additional information:

  • Vaccines will be available to elders 65 years age group first, then 55 and older age group. Number of persons vaccinated will be dependent on the number of vaccine doses received by Ponca Health Services.
  • Ponca Health Services is not able to offer home visits at this time due to vaccine storage/use requirements.
  • If you have not been seen at either Fred LeRoy Health and Wellness or Ponca Hills Health and Wellness in the past 3 years, please still complete the interest form with your contact information and good time for a staff member to contact you. A Ponca Health Services staff member will contact you regarding the registration process and schedule the vaccination.
  • If you have been seen and have an up-to-date registration at Fred LeRoy Health and Wellness Center or Ponca Hill Health and Wellness Center, please complete the form to include a good contact number.
  • Ponca Health Staff will contact persons completing the interest form when the COVID vaccine has been received. Please do not call the clinic regarding the vaccination, as the clinic is still serving patients. Instead, please call 402-738-3169 with any questions regarding pre-registration for the COVID19 vaccine (55 years & Up). The expected timeframe to receive a call from a Ponca Health Staff member is end of January to the middle of March 2021.
  • Ponca Health Services serves members of federally recognized tribes. Proof of tribal enrollment is required for registration purposes (Enrollment ID, Abstract, CDIB, etc.)