This form is ONLY for IMMUNOCOMPROMISED age 12+ Individuals receiving a THIRD DOSE of MODERNA or PFIZER who live in NY State.

Your Email Address *

Confirmation of appointment will be sent to this email.

Pick a Vaccine Site

# People You Are Scheduling: Max: 1

Pick a Date *

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Pick a Vaccine, Location, & Time *

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Recipient

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1st Vaccine Date *

2nd Vaccine Date *

1st Vaccine Type *

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

Insurance Information

The vaccine is available at no cost to you. Insurance information is collected for administrative purposes. Bring your insurance card with you to appointment! If you do not wish to provide your insurance information, select "No Insurance"

Insurance Type/Provider *

If "Other", Specify

Insurance ID # *

Relationship to Recipient *

Enter name of primary subscriber if relationship is not "self" of if name on card differs from recipient name entered above.

Primary Subscriber Last Name

First Name

Middle Name

Primary Subscriber Date of Birth

Primary Subscriber Gender

Enter address of primary subscriber if different than the recipient address entered above.

Primary Subscriber Address

Primary Subscriber City

State

Zip

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

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 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?*

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, a history of blood clots or are you 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.

Are you moderately or severely immunocompromised due to one or more of the medical conditions or receipt of immunosuppressive medications or treatments listed below? *
1) Active treatment for solid tumor and hematologic malignancies, 2) Receipt of solid-organ transplant and taking immunosuppressive therapy, 3) Receipt of CAR-T-cell or hematopoietic stem cell transplant (within 2 years of transplantation or taking immunosuppression therapy), 4) Moderate or severe primary immunodeficiency (e.g., DiGeorge syndrome, Wiskott-Aldrich syndrome), 5) Advanced or untreated HIV infection, 6) Active treatment with high-dose corticosteroids (i.e., ≥20mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor-necrosis (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory.

Yes No Unknown

You are ineligible for the 3rd dose. You are ineligible for the 3rd dose.

Have you received 2 previous doses of the Pfizer or Moderna COVID-19 vaccine, and was your last dose at least 28 days ago?

Yes No Unknown

Please be sure to bring documentation of your prior vaccinations to the clinic. You are ineligible for the 3rd dose. If you are unsure if you have had a dose of COVID-19 vaccine before, please contact your healthcare provider.

Have you received a previous dose of a non-FDA authorized or approved COVID-19 vaccine authorized by the World Health Organization (WHO) but not by the FDA (AstraZeneca - VAXZEVRIA, Sinovac - CORONAVAC, Serum Institute of India - COVISHIELD, Sinopharm/BIBP, COVAXIN)? *

Yes No Unknown

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.

I have read the entire list of priority groups for COVID-19 vaccination. I hereby certify that I am part of a priority group identified for COVID-19 vaccination, for the week that I am being vaccinated. I further agree that by clicking "I AGREE" and submitting this form, I am placing the legal equivalent of my handwritten signature on such certification. *

I AGREE

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Monroe County, NY - Vaccine Registration Form

Recipient

Insurance Information

Emergency Contact (optional)

Primary Care Provider (optional)

Screening Questions