KIDS AGES 5-11 PFIZER 1ST BOOSTER DOSE ONLY
Patients must be accompanied by a parent or guardian with proper consent documentation.

Your Email Address *

Confirmation of appointment will be sent to this email.

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Recipient

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Enter the dates you previously received vaccine doses for your initial series. If you did not receive a 3rd doses (3rd only applies to immunocompromised), leave that date 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 *

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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

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Emergency Contact (optional)

First Name

Last Name

Middle Name

Phone #

Relationship to Recipient

Primary Care Provider (optional)

First Name

Last Name

Phone

City

State

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Screening Questions

Will you be between the ages of 5-11 on the day of your appointment?

Yes No Unknown

Based on your age, you are not able to be vaccinated at this location/date. Please do not attest to coming to clinic, you will not be vaccinated at clinic. Please verify age of individual being vaccinated. If they do not fall in the eligible age range, they 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 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.

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.

Do you have a history of MIS-C (Multisystem Inflammatory Syndrome in Children)?

Yes No Unknown

Please discuss the risks and benefits of COVID-19 vaccination with your primary care provider. Please call your healthcare provider to determine if you have a history of MIS-C.

Have you received 2 doses of the Pfizer vaccine, the second dose being at least 5 months ago?

Yes No Unknown

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.

Have you received 3 doses of the Pfizer vaccine with the last dose being at least 3 months ago?

Yes No Unknown

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.

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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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

Emergency Contact (optional)

Primary Care Provider (optional)

Screening Questions