• Alden Pharmacy Vaccine Form

    All sections marked with an asterisk (*) must be completed to schedule a vaccination appointment. Please have your insurance cards and COVID-19 vaccine card (if applicable) available to complete this form.

  • The CDC recommends a COVID-19 booster vaccine dose for all individuals 18 and older who completed their inital series with the Janssen (Johnson & Johnson) vaccine more than 2 months ago.

  • The CDC recommends a COVID-19 booster vaccine dose for individuals who completed their initial series more than 6 months ago with Pfizer or Moderna for the following eligible groups:

    1. Individuals aged 65 or older

    2. Individuals aged 18 or older who have the following underlying health conditions:

    • cancer (current or in remission, including 9/11-related cancers)
    • chronic kidney disease
    • pulmonary disease (including but not limited to: COPD, asthma (moderate to severe), pulmonary fibrosis, cystic fibrosis, and 9/11 related pulmonary diseases
    • Intellectual and developmental disabilities including down syndrome
    • Heart conditions, including but not limited to heart failure, coronary artery disease, cardiomyopathies, or hypertension (high blood pressure)
    • Immunocompromised state (weakened immune system) including but not limited to solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, use of other immune weakening medicines, or other causes
    • Severe obesity (BMI 40kg/m2), obesity (BMI of 30kg/m2 but less than 40kg/m2), or overweight (BMI of 25kg/m2 but less than 30kg/m2)
    • Pregnant or recently pregnant
    • Sickle cell disease or thalassemia
    • Type 1 or 2 diabetes mellitus
    • Cerebrovascular disease (affects blood vessels and blood supply to the brain)
    • Neurologic conditions including but not limited to Alzheimer's Disease or dementia
    • Liver disease limited to cirrhosis, non-alcoholic fatty liver disease, alcoholic liver disease, or autoimmune hepatitis
    • Current or former smoker
    • Substance use disorder
    • Mental health disorders limited to mood disorders including depression, schizophrenia spectrum disorders

    3. Individuals aged 18 or older who live in long-term care settings

    4. Individuals aged 18 or older who work or live in high-risk settings

  • Alden Pharmacy COVID-19 Immunization Screening and Consent Form

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