COVID-19 Vaccine Registration Support for the Portland Metro Area
This service is for those who are struggling to navigate the COVID-19 vaccination websites. If you or a loved one are in need of appointment assistance, please complete the form below.  A background-checked volunteer from Positive Charge! PDX and Jewish Family and Child Service Portland will then call to help with COVID-19 vaccine enrollment. If you cannot complete this form, you may call us at 971-258-0449.
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Before contacting us, you may try these options first:
First Name
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Last Name
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Phone Number
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Can you receive text messages at this number?
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When are you available to speak with a volunteer?
Check all that apply:
Email Address
Street Address
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City
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Zip
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Date of Birth
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Please use MM/DD/YYYY format
Do you identify as black, indigenous, or a person of color (BIPOC)?
Some vaccination slots are prioritized for people in these communities
Please list any severe allergies to foods, medications, or vaccines. If none, write NONE:
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Are you allergic to polyethylene glycol (PEG) or polysorbate?
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Have any foods or medications ever caused you to experience an anaphylactic reaction (e.g. breathing difficulties)?
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Have you had ANY vaccinations in the last 14 days or plan to within 14 days of your appointment?
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Have you previously been diagnosed with COVID-19?
If so, please list the approximate date:
Please use MM/DD/YYYY format
Do you currently have any of these common COVID-19 symptoms?
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Fever, Dry cough, Tiredness, Aches and pains, Sore throat, Diarrhea, Conjunctivitis, Headache, Loss of taste or smell, a rash on skin or discoloration of fingers or toes, Difficulty breathing or shortness of breath, Chest pain or pressure, Loss of speech of movement
Have you had CLOSE CONTACT with someone who has COVID-19 in the past 14 days?
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Do you have any mobility issues we should consider when making your appointment?
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Do you prefer a drive-through option for your vaccination appointment?
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Do you require an appointment at a location where medical staff are on site?
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Approximately how far are you willing to travel for your appointment?
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Which days work best for an appointment?
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Select 'Any' or specific days
Which times work best for an appointment?
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Select 'Any' or specific days
How much advance notice do you need for your appointment?
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Would you like information about transportation to/from your appointment?
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We don't arrange transportation, but we can provide you with informational resources.
Which brand of vaccine are you seeking?
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Please note that supplies of brands are constantly changing, so we cannot guarantee a preference. Vaccine sites also reserve the right to change the vaccine administered. Due to varying availability, you may consider selecting “First Available."
Will you accept a different brand if we are unable to find your preferred brand?
We will attempt to find your preferred brand for up to 2 days.
Which vaccination dose are you requesting assistance for?
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If this is your 2nd dose, what was the date of your first dose?
Please use MM/DD/YYYY format
Are you interested in a “standby” appointment at any of the following times/places?
“Standby” appointments are for doses leftover at the end of the day. THESE DOSES ARE LIKELY, BUT NOT GUARANTEED. If none are available, you will get a guaranteed dose at the next convenient date. Note: if the standby appointment is for your first dose, you must be available for your second dose 21 days (Pfizer) or 28 days (Moderna) later.
Do you have an online Walgreens account?
Do you have an account on getvaccinated.oregon.gov?
How did you hear about us?
Is there any other relevant information you would like us to know?
E.g. if English is not your primary language, or if you need to be scheduled with another eligible person (please submit a separate form for them)
Data Privacy Consent
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Our volunteers have all been background-checked, and have been trained to protect your identity and personal information. We will not intentionally share your personal information with anyone for any reason besides scheduling a COVID-19 vaccination. However, whenever you provide personal information to any service, including public vaccination websites, there is always a risk of an unintentional data breach. Please click the box below to indicate that you understand this risk, and agree not to hold Positive Charge! PDX liable in this event:
Consent to Protect Volunteer Information
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We ask that you please not share our volunteer's personal phone number with anyone.
Questions? Need to cancel?
Contact us at the email below.
Submit