Monroe County, NY COVID-19 Vaccine Registration Form

BOOSTER DOSE REGISTRATION FORM

You are eligible for ANY brand booster shot if:

You previously received a 2nd Moderna or Pfizer shot at least 6 months ago and are 18 or older.
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

* Required Fields

Your Email Address *

Confirmation of appointment will be sent to this email.

Pick a Vaccine Site

Pick a Date *

Available date/time Unavailable Selected

Recipient

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Which brand booster do you want to receive? *

Which brand vaccine did you previously receive? *

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

1st Dose Date *

2nd Dose Date

3rd Dose Date

First Name *

Last Name *

Middle Name

Date of Birth *

Race *

Ethnicity *

Gender *

Phone * Copy From Person #1

Email * Copy From Top Email

Address * Copy From Person #1

Address (Line 2, Apt, Etc.)

City *

State *

Zip *

Special Accommodations Needed (wheelchair access, translator, etc.)

Mother's First Name (if age < 19)

Mother's (Maiden) Last Name

Emergency Contact (optional)

First Name

Last Name

Middle Name

Phone #

Relationship to Recipient

Primary Care Provider (optional)

First Name

Last Name

Phone

City

State

Zip

Screening Questions

Will you be under the age of 18 on the day of your appointment? *

Yes No Unknown

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.

Are you feeling sick today? *

Yes No Unknown

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.

In the last 10 days, have you had a COVID-19 test because you had symptoms and are still awaiting your test results or been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection or exposure?*

Yes No Unknown

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.

Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)? *

Antibody therapy and convalescent plasma for COVID-19 is a medical treatment provided to some people with COVID-19 infection.

Yes No Unknown

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.

Have you ever had an immediate allergic reaction (e.g. hives, facial swelling, difficulty breathing, anaphylaxis) to any vaccine, injection, or shot or to any component of the COVID-19 vaccine, or a severe allergic reaction (anaphylaxis) to anything?*

This allergy does not apply to mild allergic reactions such as rash only.

Yes No Unknown

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.

Are you pregnant or considering becoming pregnant? *

Yes No Unknown

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.

Do you have cancer, leukemia, HIV/AIDS or any other condition that weakens the immune system? *

Yes No Unknown

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.

Do you take any medications that affect your immune system, such as cortisone, prednisone or other steroids, anticancer drugs, or have you had any radiation treatments? *

Yes No Unknown

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.

Do you have a bleeding disorder or are you currently taking a blood thinner? *

Yes No Unknown

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.

Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart)?

Yes No Unknown

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.

Monroe County, NY COVID-19 Vaccine Registration Form

Recipient

Insurance Information

Emergency Contact (optional)

Primary Care Provider (optional)

Screening Questions