Johnson & Johnson Vaccine Appointment
!!!Please read carefully before scheduling your appointment!!!
For clients age 18 years and older use this form to make an appointment for one dose of Johnson & Johnson Covid-19 vaccine. Also please don't schedule multiple appointments, if you would like to cancel or reschedule please email us at firstname.lastname@example.org. MEDICARE PART A & B card required for 65 and older clients. For 64 and under clients prescription insurance card is required. Please wear short sleeve shirts to your appointment.
1st Shot Appointment
Vaccine Recipient Name
Date of Birth
Please enter a valid phone number.
Note: Confirmation email will go to this email
Vaccine Recipient Physical Address
Street Address Line 2
District of Columbia
Gender at birth
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
Mother's Maiden Name
Required for proper vaccine documentation
Primary Vaccine Site
Primary Care Provider Name
Emergency Contact Name
Relationship to Emergency Contact
Phone Number of Emergency Contact
COVID-19 Vaccine Screening Questions
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication?
6. Have you received any vaccine in the last 14 days?
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you have a bleeding disorder or are you taking a blood thinner?
9. Are you currently pregnant or breastfeeding?
10. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
11. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
Consent (check each box below after reading and prior to signing the form)
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. 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 Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.
For insured/uninsured patients, please select at least one of the following that you will bring with you to your appointment.
State Issued Picture ID
Medicare Part A & B Card (65 and older clients)
Prescription insurance card (64 and under clients)
Signature of Person to Receive Vaccine & EUA /VIS:
Should be Empty: