4211 St. Rt. 44 Suite 207-208 (NEW Center MOB)
Rootstown, OH 44272
COVID-19 Vaccine Clinics
Location: 2nd Floor Medical Office Building (MOB) in NEW Center - NEOvations Pharmacy Services/NEOMED Clinical Services
COVID-19 Vaccine Administration Form
Which COVID-19 vaccine would you like to receive?
Pfizer-BioNTech (12 years and older)
Pfizer-BioNTech (5 - 11 years old)
Pfizer-BioNTech (6 months - 4 years old)
Moderna (6 months - 5 years old)
Please select the time you would like to receive your Pfizer COVID-19 vaccine (12 years and older).
Please select the time you would like to receive your Pfizer COVID-19 vaccine (5-11 years).
Date of Birth (MM/DD/YYYY)
Wish not to disclose
Weight (only if
Primary Care Provider (PCP):
Please bring your Medical/Rx insurance card to your vaccine appointment. If you do not have Medical/Rx insurance you will need to provide your Social Security number.
Do you have Medical/Rx Insurance?
Social Security Number (if no insurance)
Medical Insurance Card Image
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Choose a file
MEDICAL Insurance Provider Name (eg: Aetna, Cigna, SummaCare, etc.)
MEDICAL Insurance ID #
MEDICAL Insurance Group Number
Rx Insurance ID
Rx BIN Number
Rx Group (GRP) Number
Rx PCN Number
Are you feeling sick today?
Have you ever received a dose of the COVID-19 vaccine?
Which COVID-19 vaccine have you received?
Pfizer - BioNTech
Janssen (Johnson & Johnson)
How many total doses of COVID-19 vaccine have you received?
2-doses + additional dose
Dose-1 Date Received: (MM/DD/YYYY)
Dose-2 Date Received: (MM/DD/YYYY)
Additional Dose Date Received: (MM/DD/YYYY)
Do you have a health condition or are you undergoing treatment that makes you moderately or severely immunocompromised?
In the past 10 days, have you had a positive test or doctor's diagnosis for COVID-19?
In the past 90 days, have you received plasma or monoclonal antibodies for COVID-19?
In the past 90 days, have you been diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection?
Have you ever had an allergic reaction to a COVID-19 vaccine component (Polyethylene glycol or PEG; POLYSORBATE), or to a previous dose of a COVID-19 vaccine?
Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable
Does any of the following apply to you? CHECK ALL THAT APPLY
Am a female between ages 18 and 49 years old
Am a male between ages 12 and 29 years old
Have a history of myocarditis or pericarditis
Have been treated with monoclonal antibodies or convalescent serum to prevent or treat COVID-19
Diagnosed with Multisystem Inflammatory Syndrome (MIS-C or MIS-A) after a COVID-19 infection
Have a bleeding disorder
Take a blood thinner
Have a history of heparin-induced thrombocytopenia (HIT)
Am currently pregnant or breastfeeding
Have received dermal fillers
Have a history of Guillain-Barré Syndrome (GBS)
Signature (Patient or Legal Guardian if 5 18 years)
Print Full Name
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