Monroe County, NY COVID-19 Vaccine Registration Form

  BOOSTER DOSE REGISTRATION FORM  

You are eligible for ANY brand booster shot if:

  1. You previously received a 2nd Moderna or Pfizer shot at least 6 months ago and are 18 or older.
  2. You previously received a single Janssen (Johnson & Johnson) shot at least 2 months ago and are 18 or older.

CLICK HERE FOR MORE INFORMATION ON ELIGIBILITY

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Enter the dates you previously received vaccine doses. If you did not receive 2nd or 3rd doses, leave those dates blank.

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Screening Questions
Based on your age, you are not able to be vaccinated. Please do not attest to coming to clinic, you will not be vaccinated at clinic. Please verify age of individual being vaccinated. If under the required age the individual will not be eligible.
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.
Antibody therapy and convalescent plasma for COVID-19 is a medical treatment provided to some people with COVID-19 infection.
If you received antibody therapy or convalescent plasma for COVID-19 infection, you will need to schedule your vaccination 90 days after your last treatment. Please do not schedule your appointment if it has not been 90 days post treatment. Antibody therapy or convalescent plasma is a treatment for COVID-19, if you have not received either of these as treatment for COVID-19 infection, please adjust the answer to your screening question.
This allergy does not apply to mild allergic reactions such as rash only.
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.
Someone will review the answers to these questions with you at the clinic. Someone will review the answers to these questions with you at the clinic.
Someone will review the answers to these questions with you at the clinic. Someone will review the answers to these questions with you at the clinic.
Someone will review the answers to these questions with you at the clinic. Please call and confirm with your doctor if you have a qualifying condition and adjust the answer to your screening question and continue. If answer remains unknown, you will be referred to medical evaluation at clinic.
Someone will review the answers to these questions with you at the clinic. Please call and confirm with your doctor if you have a qualifying condition and adjust the answer to your screening question and continue. If answer remains unknown, you will be referred to medical evaluation at clinic.
Someone will review the answers to these questions with you at the clinic. Please talk to your health care provider or employer if you are unsure if you are at an increased risk of COVID-19 infection due to occupational / institutional setting. If answer remains unknown you will be referred to medical evaluation at clinic.
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.
Thrombosis with thrombocytopenia syndrome (TTS) is a rare condition diagnosed by your health care provider in which people have blood clots and low platelet counts.
Based on your answer, you are not eligible for a Janssen (Johnson & Johnson) booster. You will need to receive a Pfizer or Moderna booster.
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.