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Healthy people create healthy communities, and all of us should be able to access the right care, at the right time, for the right cost.

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Sign Up for the Sunrise COVID19 Vaccine Waiting List.

We will contact you when there is space available at an upcoming vaccine clinic.

If you prefer to call to sign up, contact us at:

970-346-2587 (English) OR 970-346-2589 (Espanol)

First Name

Last Name

Address (including city)

Phone

Date of Birth*

Employer/Industry

Your current primary care provider:

Sunrise Community Health

Banner

U C Health

Kaiser

Other/None

Insurance: (There is no fee for the vaccine. We may bill your insurance for an administrative fee. We will not bill patients.)

Medicaid

Medicare

CHP+

CICP

Private

No insurance

What is your preferred language?

English

Spanish

Other

Prefer Latino Equity Clinic on March 14, 2021

Yes

If you have any current high risk** medical conditions, please indicate how many: (see below for examples of high risk)

One condition

Two conditions

Three conditions

Four or more conditions

Thanks for signing up! We will contact you as space becomes available

**High risk medical conditions include:

-Cancer-currently receiving treatment or treated within the last month;

-Chronic kidney disease

-COPD

-Diabetes Mellitus

-Down Syndrome

-Specific heart conditions: heart failure, cardiomyopathies or coronary artery disease, severe valvular/congenital heart disease

-Obesity (BMI > 30 kg/m2)

-Sickle cell disease

-Solid organ transplant

I-ndividuals with disabilities who require direct care in their home

-People with disabilities that prevent them from wearing a mask

Careers

Billing + Financial Info.

Sunrise Community Health Administrative Office

2930 11th Avenue, Evans, CO 80620.

970.350.4606

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