Language
  • English (US)
  • General Vaccine Form

    164 5th Ave, Brooklyn, NY 11217
  • Vaccine Options

    Select up to 2 vaccines you want to receive
  • You are not eligible for the RSV vaccine.

  • 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.

  •  - -Pick a Date
  •  - -
    Pick a Date
    • Section - Form Body 
    • Patient Information

    •  - -Pick a Date
    •  - -
      Pick a Date
    • 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)
    • Upload File
      Drag and drop files here
      Choose a file
      Cancelof
    • Upload File
      Drag and drop files here
      Choose a file
      Cancelof
    • Patient Questions

    • Section - Prevaccination Checklist for COVID-19 Vaccines 
    • Prevaccination 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.)

    •  - -Pick a Date
    • Section - First Booster Dose Eligibility 
    •  - -Pick a Date
    •  - -Pick a Date
    •  - -Pick a Date
    • Section - Second Booster Dose Eligibility 
    •  - -Pick a Date
    •  - -Pick a Date
    • 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.

    • Clear
    •  / /
      Pick a Date
    •  
    •  
    •  
    • Should be Empty: