Monroe County, NY - Vaccine Registration Form

 COVID-19 BIVALENT BOOSTER REGISTRATION FORM  

You may receive the Moderna (age 18+) or Pfizer (age 12+) bivalent booster if it has been at least two months since your completed initial vaccination or booster.

CDC ELIGIBILITY INFORMATION

* Required Fields

Confirmation of appointment will be sent to this email.
County Fleet Center - 145 Paul Road, Rochester, 14624
Available date/time Unavailable Selected

Recipient

Enter the dates you previously received vaccine doses for your initial series. If you did not receive 2nd or 3rd doses (3rd only applies to immunocompromised), leave those dates blank.

Emergency Contact (optional)
Primary Care Provider (optional)
Screening Questions
If you are sick on the day of the clinic you will be referred to medical evaluation. If you are sick on the day of the clinic you will be referred to medical evaluation.
If you have you had a positive COVID-19 test within the last 10 days or are currently under isolation or quarantine please stay home and do not attend clinic. Your appointment must be scheduled after your isolation or quarantine has ended. If you are awaiting test results, you have had a positive COVID-19 test within the last 10 days or have been told to isolate or quarantine please stay home and reschedule after you receive your result or are no longer in quarantine or isolation.
You will be referred for Medical Evaluation on the day of clinic to discuss your allergy. If the Medical Evaluator clears you for vaccination, then you will need to be observed for 30 minutes after you receive the vaccine. You will be referred for Medical Evaluation on the day of clinic to discuss your allergy. If the Medical Evaluator clears you for vaccination, then you will need to be observed for 30 minutes after you receive the vaccine.
If you are pregnant or considering becoming pregnant, you should consider discussing the risks and benefits of COVID-19 vaccine during pregnancy with your OB/GYN prior to clinic. If you are pregnant or considering becoming pregnant, you should consider discussing the risks and benefits of COVID-19 vaccine during pregnancy with your OB/GYN prior to clinic.
If you have a condition that weakens your immune system, you may wish to contact your health care provider prior to clinic to discuss the risks and benefits of the COVID-19 vaccination. You may wish to confirm with your doctor a history of any conditions that weaken your immune system prior to clinic. If answer remains unknown, you will be offered to speak with medical evaluation at clinic.
If you take a medication which affects your immune system, you may wish to contact your health care provider prior to clinic to discuss the risks and benefits of the COVID-19 vaccination. Please confirm with your doctor if any medications you take affect your immune system prior to clinic or alter the answer to your screening question and continue.
Please contact the healthcare provider managing your bleeding disorder or blood thinner about the safety of getting a vaccine in your arm, prior to coming to clinic. Please call and confirm with your doctor if you have a bleeding disorder or are taking a blood thinner and adjust the answer to your screening question and continue. If answer remains unknown, you will be referred to medical evaluation at clinic.
Please discuss the risks and benefits of COVID-19 vaccination with your primary care provider and cardiologist Please call your healthcare provider to determine if you have ever had an episode of myocarditis or pericarditis.
Please be sure to bring documentation of your prior vaccinations to the clinic. If you are unsure if you have had a dose of COVID-19 vaccine before, please contact your healthcare provider.
Please be sure to bring documentation of your prior vaccinations to the clinic. If you are unsure if you have had a dose of COVID-19 vaccine before, please contact your healthcare provider.
Please be sure to bring documentation of your prior vaccinations to the clinic. If you are unsure if you have had a dose of COVID-19 vaccine before, please contact your healthcare provider.
Please be sure to bring documentation of your prior vaccinations to the clinic. If you are unsure if you have had a dose of COVID-19 vaccine before, please contact your healthcare provider.
If you are unsure, please contact your healthcare provider.
This form is only for the 1st dose of the bivalent booster shot. If you are unsure if you have had a dose of COVID-19 vaccine before, please contact your healthcare provider.
Please bring the vaccine information to your appointment including the type of vaccine, how many doses you received, and the dates the dose(s) were received. If you are unsure if you have had a dose of COVID-19 vaccine before, please contact your healthcare provider.
YOU WILL NOT BE ABLE TO EDIT THIS INFORMATION AFTER CLICKING THE SUBMIT BUTTON BELOW. PLEASE MAKE SURE ALL INFORMATION IS CORRECT.