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  • General Vaccine Form

    500 4th Ave, Brooklyn, NY 11215

  • Vaccine Options

    Select up to 2 vaccines you want to receive

  • Your vaccine choices are incompatible with each other. Please change your vaccine choices to be different from each other. You cannot pair two different flu shots, two different COVID-19 vaccines, or other choices intended to protect against the same virus.

  • Moderately to Severely Immunocompromised Eligibility:

    • PFIZER
      • 3rd DOSE: 5 years and older at least 4 weeks (28 days) after the final dose of their vaccine series
      • 1ST BOOSTER: 5 years and older at least 3 months after Pfizer 3rd dose
      • 2nd BOOSTER: 12 years and older at least 4 months after 1st booster
    • MODERNA
      • 3rd DOSE: 18 years and older at least 4 weeks (28 days) after the final dose of their vaccine series
      • 1ST BOOSTER: 18 years and older at least 3 months after Moderna 3rd dose -OR- at least 2 months after Janssen 2nd dose
      • 2nd BOOSTER: 18 years and older at least 4 months after 1st booster

  • mRNA COVID-19 Vaccine Booster Eligibility:

    • OMICRON BOOSTER (12+ yr): 2 months after last.
    • PFIZER 1St BOOSTER (5-11 yr): 5 months after second dose.
    • Section - Attestation 

    • Attestation for Additional Dose Eligibility

    • Patient must meet at least one of the following Moderately or Severely Immunocompromised Criteria to receive a third dose:

      • Acute treatment for solid tumor and hematologic malignancies
      • Receipt of solid-organ transplant and taking immunosuppressive therapy
      • Receipt of CAR-T-cell or hematopoietic stem cell transplant (within 2 years of transplantation or taking immunosuppression therapy)
      • Moderate or severe primary immunodeficiency (e.g. , DiGeorge,Wiskott-Aldrich syndromes)
      • Advanced or untreated HIV infection
      • Active treatment with high-dose corticosteroids (i.e.,≥20mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, TNF blockers, and other biologic agents that are immunosuppressive or immunomodulatory
      • Chronic conditions associated with varying degrees of immune deficit, such as asplenia, sickle cell and chronic renal disease.
      • Other diagnosed chronic condition with equivalent moderate to severe level of immunocompromised
    • Section - COVID-19 Last-dose Details 

    • COVID-19 Last-dose Details

    • If you haven't received the last primary dose of your COVID-19 vaccine series yet, you can't schedule any additional doses or boosters.

      If you don’t meet the current eligibility recommendations, and it has not been long enough since you were fully vaccinated, you can’t schedule an additional dose or booster.

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    • It has not been long enough since your last-dose from today's date. You are not eligible for one or more of your vaccine choices, and cannot proceed.

    • Section - Form Body 

    • Patient Information

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    • You do not meet the age requirement for one or more of your vaccine choices. Due to this, you will not be able to submit this form unless you change your vaccine choice(s).

      • Flu Shot (4+ yr)
      • Flu Shot for Seniors (65+ yr)
      • COVID-19 Omicron Booster Pfizer 12+ (12+ yr)
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    • Patient Questions

    • Section - Prevaccination Checklist for COVID-19 Vaccines 

    • Prevaccination Checklist for COVID-19 Vaccines

    • The following questions about allergic reactions would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.)

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    • Section - First Booster Dose Eligibility 
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    • Section - Second Booster Dose Eligibility 
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    • Section - Form Consent 

    • Consent

    • I authorize Park Chemists to report the administration of this immunization to the Citywide Immunization registry (CIR) and my Primary Health Care Provider.

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