My Pharmacy & Optical COVID-19 Vaccine Registration Form ** Pfizer only**

**PFIZER Vaccine Only Schedule**
This is my first, second, or third dose of the Pfizer Vaccine: *

First Dose Second Dose 1st Booster 2nd Booster *see eligibility details under FAQ's on website Third Dose *immunocompromised or less than 5 years of age
Have you confirmed that you are eligible to receive the above dose based upon age and timeline requirements from your last dose?

Yes No
Appointment *

Please complete the below form.
Salutation
First Name *
Middle Name
Last Name *
Date of Birth *

Month Day Year
Date
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
By completing these fields you are attesting that the patient is 6 months of age or older? *

The patient is 6 months of age or older and wants the PFIZER vaccine.
Parent or Legal Guardian Name (Only applicable if patient is 15 years of age or younger)

First Name Last Name
Parent or Legal Guardian Date of Birth (Only applicable if patient is 15 years of age or younger)

Month Day Year
Date
Please review and check ALL the boxes below *

Please bring your ID, insurance card, and vaccine card (if applicable) with you to your appointment. If you have Medicare we will need your Medicare Part B card (red/white/blue card). Please arrive as close to your appointment time as possible to prevent traffic congestion. We ask that you do not get into line until 5 minutes before your appointment time to prevent traffic concerns. COVID vaccinations will be given outside at the back of our pharmacy under the tent and entrance to COVID vaccination line will be the entrance off St. Peters Church Rd. Anyone arriving into the parking lot from HWY 378 will be required to exit and reenter from St. Peters Church Rd. Please allow 30 minutes upon arrival. You will be required to remain on site for 15 minutes for observation. Additional instructions will be provided upon arrival. If the patient is 15 years of age or less, a parent or legal guardian must accompany the patient during the vaccine process. If readily accessible, please bring the child's ID or birth certificate.
Please review the following:

Pfizer EUA Fact Sheet - http://labeling.pfizer.com/ShowLabeling.aspx?id=14472

V-Safe Registration - Get vaccinated. Get your smartphone. Get started with v-safe. (cdc.gov)
Please make sure you review the "Pfizer EUA Fact Sheet" and "V-Safe Registration" above. *

I attest that I have downloaded and reviewed "Pfizer EUA Fact Sheet" and "V-Safe Registration" above.
Please download and print out the form below from the CDC.

https://www.cdc.gov/vaccines/covid-19/downloads/pre-vaccination-screening-form.pdf
Please agree to the following *

I have downloaded and printed out page 1 of the form from the CDC and Pfizer link above. I will fill this form out and bring it to my appointment.
Should be Empty:

**PFIZER Vaccine Only Schedule**

Please complete the below form.

PFIZER Vaccine Only Schedule