Pfizer COVID-19 Immunization Appointment Scheduling

Pfizer COVID-19 Immunization Scheduling Form

PLEASE BRING YOUR VACCINE CARD, INSURANCE CARDS AND ID TO YOUR APPOINTMENT. This form is ONLY for those age 12 and older. If you are in need of the Pfizer for age 5-11, please see other scheduling link on Donlonrx.com
Please specify whether this vaccination will be your FIRST, SECOND, or BOOSTER dose of the Pfizer COVID-19 vaccine: *

First dose Second dose 1st booster dose 2nd booster dose (only for age 50 and old OR immunocompromised patients)
Are you immunocompromised?

Yes No
People are considered to be moderately or severely immunocompromised (have a weakened immune system) due to several types of conditions and treatments. Examples include:

-Been receiving active cancer treatment for tumors or cancers of the blood
-Received an organ transplant and are taking medicine to suppress the immune system
-Received chimeric antigen receptor (CAR)-T-cell therapy (a treatment to help your immune system attach to and kill cancer cells) or received a stem cell transplant (within the last 2 years)
-Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)
-Advanced or untreated HIV infection
-Active treatment with high-dose corticosteroids or other drugs that may suppress their immune response
Please indicate the last date you received a COVID-19 vaccine. You may receive a 1st BOOSTER dose of the Pfizer COVID-19 vaccine 5 MONTHS following your 2nd Moderna/Pfizer dose OR 2 months after your J&J dose. If age 50 or older or immunocompromised you may receive 2nd booster 4 MONTHS following 1st booster dose. Please indicate the last date you received a COVID vaccine *

Month Day Year
Date
What vaccine did you initially receive?

Moderna J&J Pfizer
Please indicate the date you received your FIRST dose of the Pfizer COVID vaccine:

Month Day Year

Pfizer COVID-19 Immunization Scheduling Form

COVID-19 Vaccination Appointment

Patient Information