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First Name
Last Name
Business Email
Phone Number
Clinic group name
Number of clinics within group
Headquarter state AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Not located in the United States
Additional states (if applicable)
Are you enrolled in your state vaccine program? YesNo
Are you currently administering a COVID-19 vaccine? YesNo
What standard refrigeration does your clinic have to keep the COVID-19 vaccines in? Refrigerated (2°C-8°C)Frozen (-15°C-25°C)Ultra Frozen (-60°C-80°C)None
What EMR do you currently use?
Do you currently use a patient scheduling and queuing tool? Atlas.MD Experity (Clockwise.MD) DocASAP DocResponse ECW / Healow EPIC ER Express Healthpost InQuicker Jellyfish My Health Direct No Solution in Place NextPatient Not Applicable Phressia QLess Radix Seamless Solv Other Yosi Health ZipPass ZocDoc
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