5-21-2021 Pfizer Vaccinations for 12 & up at GR

1
Vaccine Recipient Name* This field is required.If you have multiple children, please fill this out for each individual child.
First Name
Last Name
2
Appointment* This field is required.Please schedule an appointment for each child. If you have multiple children you can bring them together and we will do them at the same time. However, due to limitations of the software we still need you to pick separate times on this scheduler.
3
Date of Birth* This field is required.
Date
Month
Day
Year
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number* This field is required.
Area Code
Phone Number
6
Race* This field is required.Please select the one that best fits you.
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Other
7
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
8
Primary Care Physician* This field is required.
9
Answer the questions below.* This field is required.
Yes
No
Don't Know
Are you sick today?
Have you ever had a severe allergic reaction (e.g. anaphylaxis requiring hospitalization or Epipen) to something?
Have you had a severe reaction to a vaccine?
Have you had a positive test for Covid-19 or has a doctor ever told you had Covid-19?
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19?
Have you ever been diagnosed with Multisystem Inflammatory Syndrome after a Covid 19 infection or have had Guillain-Barre Syndrome?
Do you have a weakened immune system caused by something such as HIV, cancer, or do you take immunosuppressive drugs?
Do you have a bleeding disorder or on a blood thinner?
Are you sick today?
Have you ever had a severe allergic reaction (e.g. anaphylaxis requiring hospitalization or Epipen) to something?
Have you had a severe reaction to a vaccine?
Have you had a positive test for Covid-19 or has a doctor ever told you had Covid-19?
Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as a treatment for COVID-19?
Have you ever been diagnosed with Multisystem Inflammatory Syndrome after a Covid 19 infection or have had Guillain-Barre Syndrome?
Do you have a weakened immune system caused by something such as HIV, cancer, or do you take immunosuppressive drugs?
Do you have a bleeding disorder or on a blood thinner?
Yes
No
Don't Know
Yes
No
Don't Know
Yes
No
Don't Know
Yes
No
Don't Know
Yes
No
Don't Know
Yes
No
Don't Know
Yes
No
Don't Know
Yes
No
Don't Know
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10
Consent

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (insert link to EUA), a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.

I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
11
Signature of Individual or Parent/GuardianParent/Guardian must sign if under 18 years old
Clear
12
EmailPlease enter to receive email confirmation. If you do not receive an email confirmation, as long as you get to the last Thank You! page your submission has gone through and you are scheduled.
example@example.com
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