Monroe County, NY - Vaccine Registration Form

GENERAL VACCINATION REGISTRATION FORM

Use this form to schedule an appointment at the Monroe County Public Health Department for any of the following vaccines. Online Scheduling is only being offered until 10/31/23.

Diphtheria
Pertussis
Tetanus
Polio
Haemophilus influenzae B (Hib)
Measles
Mumps
Rubella

Hepatitis A
Hepatitis B
Varicella (chicken pox)
Influenza
Meningococcal disease
Pneumococcal disease
HPV

* Required Fields

Your Email Address *

Confirmation of appointment will be sent to this email.

Pick a Vaccine Site

# People You Are Scheduling: Max: 4

Pick a Date *

Available date/time Unavailable Selected

Pick a Vaccine, Location, & Time *

Recipient

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Which vaccines are needed? *

e.g. Diphtheria, Pertussis, Tetanus, Polio, Haemophilus influenzae B (Hib), Measles, Mumps, Rubella, Hepatitis A, Hepatitis B, Varicella (chicken pox), Influenza, Meningococcal disease, Pneumococcal disease, HPV.

Why do you need these vaccines? *

e.g. School, Work, Travel, Immigration, Special Health Needs, Referred by doctor, Tuberculosis screening: PPD, Health, Other.

First Name *

Last Name *

Middle Name

Date of Birth *

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

Guardian/Emergency Contact (optional)

First Name

Last Name

Middle Name

Phone #

Relationship to Recipient

Add Another Person

YOU WILL NOT BE ABLE TO EDIT THIS INFORMATION AFTER CLICKING THE SUBMIT BUTTON BELOW. PLEASE MAKE SURE ALL INFORMATION IS CORRECT.

Monroe County, NY - Vaccine Registration Form

Recipient

Insurance Information

Guardian/Emergency Contact (optional)