COVID-19 Vaccine Appointment Scheduling and Consent Formd
2100 Dorchester Ave. Dorchester, MA 02124 Tel: (617) 322-9265
Appointment
*
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Unknown
Race
*
American Indian or Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Black or African American
White
Other
Ethnicity
*
Hispanic
Not Hispanic or Latino
Unknown
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Allergies
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Primary Care Physician (PCP) Name
First Name
Last Name
PCP Phone Number
Please enter a valid phone number.
Screening Questions:
1. Are you feeling sick today?
*
Yes
No
Don't know
2. Have you ever received a dose of COVID-19 Vaccine?
*
Yes
No
3. Which vaccine are you looking for today?
*
Pfizer COVID Bivalent Vaccine (Last day 11/18/22)
Moderna COVID Bivalent Vaccine
4. Have you ever had a severe allergic reaction (e.g. anaphylaxis) in the past? Example: a reaction for which you were treated with epinephrine or EpiPen®, or for which you had to go to the hospital.
*
Yes
No
Don't know
Was the severe allergic reaction after receiving a COVID-19 vaccine?
*
Yes
No
Don't know
Was the severe allergic reaction after receiving another vaccine or injectable medication?
*
Yes
No
Don't know
Was the severe allergic reaction related to Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
*
Yes
No
Don't know
Was the severe allergic reaction related to receiving Polysorbate or products containing Polysorbate?
*
Yes
No
Don't know
5. Have you ever had a severe allergic reaction to another vaccine or an injectable medication?
*
Yes
No
Don't Know
6. Have you received any vaccine in the last 14 days?
*
Yes
No
Don't Know
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
*
Yes
No
Don't Know
8. Have you received monoclonal antibodies or convalescent serum as treatment for COVID-19 in the past 90 days?
*
Yes
No
Don't Know
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
*
Yes
No
Don't Know
10. Do you have a bleeding disorder or are you taking blood thinner?
*
Yes
No
Don't Know
11. For women: Are you pregnant or breastfeeding?
Yes
No
Don't Know
For uninsured patients, please select at least one of the following that you will bring with you to your appointment. This is needed in order to have your vaccine administration fee paid for by the United States Health Resource & Services Administration's COVID-19 Program.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Are you 18 years and younger
*
Yes
No
Signature of person to receive vaccine & EUA/VIS
*
Name of parent, guardian, or authorized representative
First Name
Last Name
Signature of parent, guardian, or authorized representative
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: