GuidePoint Vaccine Questionnaire and Scheduling

Vaccine Questionnaire and Scheduling
For kids vaccines (under the age of 12) please call the store to see availability and schedule an appointment. Thank you!
Pick a location to receive the vaccine. Vaccine will be given at the GuidePoint Pharmacy that you indicate below:*
Please click on the following link if you would like to receive a PFIZER vaccine in Aitkin:

https://hipaa.jotform.com/213264059609155

Please click on the following link if you would like to receive a MODERNA vaccine in Aitkin:

https://hipaa.jotform.com/212935651779165
Pick which vaccine(s) you would like to receive at your appointment

COVID-19 Vaccine - Original PfizerCOVID-19 Vaccine - Pfizer Bivalent BoosterCOVID-19 Vaccine - Moderna Bivalent BoosterHepatitis AHepatitis BGardasil (HPV)PneumoniaVaricella (Chickenpox)Zoster (Shingles)Tetanus (Td)Whooping Cough (Tdap, DTaP)
Vaccines will only be given if the patient is elgible. If you are not sure if you are elgible for the vaccine please call the pharmacy or go to the CDC link below:

https://vaccinateyourfamily.org/which-vaccines-does-my-family-need/?gclid=EAIaIQobChMIwOmGuPan9gIVxO7jBx1yZwcBEAAYASAAEgKR0PD_BwE
Pick which dose you are requesting:*

1st Dose2nd DoseBooster
We are now only doing 12+ PFIZER for COVID-19 vaccine currently.
GuidePoint - Marshall does not use online scheduling. Please call 507-401-8482 to inquire about vaccines.
Name*
Date of Birth (CIP)*

MonthDayYear
Date of Birth *

MonthDayYear
GuidePoint - Longville does not use online scheduling. Please call 218-363-2640 to inquire about vaccines.
GuidePoint locations in Edgerton, Fulda, and Slayton do not use online scheduling. Please call the Slayton location at 507-873-2075 to inquire about vaccines.
Todays Date

MonthDayYear
Date
ALL12+ vs 5-11
BRD 12+ vs 5-11
CI 12+ vs 5-11
CalcBrd
Gender*
Race (required by CDC)*
Ethnicity (required by CDC)*
calcCI
Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mother's Maiden Name (Used for State Immunization Registry Purposes ONLY)
Do you have insurance? *** You WILL NOT be charged for the vaccine the COVID-19 vaccine but other vaccines may have a co-pay depending on insurance.****

YesNo
Please bring you insurance card with you to your appointment. Regardless fo your insurance coverage you WILL NOT be charged for COVID-19 vaccine.

For non-COVID vaccines you may have a co-pay. Please call your designated pharmacy to inquire about cost.
Please bring a photo ID with you to your appointment (if you have one). Regardless of your insurance coverage you WILL NOT be charged for COVID-19 vaccine. With your photo ID, we can bill the state to help cover staffing costs.

If you do not have insurance for non-COVID-19 vaccines please contact our Brainerd location. GuidePoint-Brainerd can offer special pricing on vaccines to patients without insurance.
Please write down your appointment time! You WILL NOT receive an email confirmation. Your appointment is confirmed if you see the green checkmark after you click Submit.

Blue time slots are available.
Grey time slots are filled.
Aitkin non-COVID-19 Schedule*
Brainerd non-COVID-19 Schedule*
Brainerd Pfizer COVID-19 Schedule*
Brainerd Booster COVID-19 Schedule*
Crosby non-COVID schedule*
Crosby PFIZER Schedule*
Crosby Booster Schedule*
Nisswa PFIZER Schedule*
Nisswa Booster Schedule*
Nisswa non-COVID Schedule*
BP non-COVID Schedule*
BP PFIZER Schedule*
BP Booster Schedule*
Pine River non-COVID Schedule*
Pine River PFIZER Schedule*
Pine River Booster Schedule*
GuidePoint COVID-19 Vaccine

A pharmacist may ask more questions at your appointment if any questions are answered yes.
Are you sick today?*

YesNo
In the past two weeks have you tested positive for Covid-19 or are you currently being monitored for COVID-19?*

YesNo
Have you had any COVID-19 symptoms in the past 2 weeks: fever or chills, cough, shortness of breath, muscle or body aches, new loss of taste or smell, sore throat, nausea or vomiting, or diarrhea?*

YesNo
Do you have allergies to medications, food, or vaccine?*

YesNo
If yes, what allergies do you have?
Do you have a history of Guillain-Barre Syndrome?*

YesNo
Have you ever had a serious reaction (e.g. anaphylaxis) after receiving an immunization or injectable therapy (medications administered into the muscle, into the vein, or under the skin)?*

YesNo
If yes, what was the reaction?*
Are you currently being treated for a long-term health problem such as heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia or other blood disorder?*

YesNo
If yes, what long-term health care problem?*
Are you currently being treated for cancer, leukemia, AIDS, or any other immune system problem?*

YesNo
If yes, what are you being treated for?*
Are you currently taking cortisone, prednisone, other steroids or anti-cancer drugs, or have you had X-ray treatments?*

YesNo
If yes, what?*
Have you ever fainted or felt dizzy after receiving an immunization?*

YesNo
Have you had a seizure, brain, or nerve problem?*

YesNo
If yes, what?*
During the past year, have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin?*

YesNo
If yes, what?*
Have you received a vaccine in the past 4 weeks?*

YesNo
If yes, what vaccine?
Are you allergic to eggs?*

YesNo
If yes, what was your reaction?*
Are you allergic to latex?*

YesNo
If yes, what was your reaction?*
Have you received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment in the past 90 days?*

YesNo
Did you have a delayed allergic reaction at the injection site (e.g., skin rash, itching) after a previous dose of COVID-19 vaccine?*

YesNo
If yes, what was the reaction?*
For women: Are you pregnant or is there a chance you could become pregnant during the next month?*

YesNo
Additional Questions or Comments:
A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of any vaccine causing serious harm, or death, is extremely small. Local symptoms may include: slight tenderness, redness, itching or swelling at the site of injection. Systemic symptoms may include: fever, malaise and muscle pain. Other systemic symptoms may occur infrequently. These reactions usually begin 6 to 12 hours after immunization and can persist for a few days. Immediate presumable allergic reactions such as hives, angioedema, allergic asthma or systemic anaphylaxis occur rarely after immunization. These reactions may result from hypersensitive reactions in people with severe egg allergy, and such people should not be given certain vaccines that contain eggs. People with documented immunoglobulin E (IgE)-mediated hypersensitivities to eggs or any other vaccine components, including thimerosal, may also
be at increased risk of reactions from immunizations.

In the case of a severe reaction such as a high fever, behavior changes or flu-like symptoms that occur after vaccination, see a doctor right away. Signs of an allergic
reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heartbeat, or dizziness within a few minutes to a few hours after
the shot.

By pressing submit below I am acknowledging that I have read the adverse reactions associated with the administration of vaccines. A copy of the vaccine manufacturer’s drug information sheet is available on request. I believe the benefits outweigh the risks and I voluntarily assume full responsibility for any reactions that may result from either my receipt of the immunization(s) or the receipt of the immunization(s) by the person named below for whom I am the legal guardian (‘Ward’). My medical record may be shared with my physician or other healthcare provider and the medical record of my Ward may be shared with his/her physician or other healthcare provider. I am requesting that the immunization(s) be given to me or my Ward. I, for myself and on behalf of my Ward, and each of our respective heirs, executors, personal representatives and assigns, hereby release GuidePoint Pharmacy, and its affiliates, subsidiaries, divisions, directors, contractors, agents and employees (collectively “Released Parties”), from any and all claims arising out of, in connection with or in any way related to my receipt and the receipt by my Ward of this or these immunization(s). Neither GuidePoint Pharmacy nor any of the Released Parties shall, at any time or to any extent whatsoever, be liable, responsible or any way accountable for any loss, injury, death or damage suffered or sustained by any person at any time in connection with or as a result of this vaccine program or the administration of the vaccines described above. GuidePoint Pharmacy will use and disclose your personal and health information or the personal and health information of your Ward, to treat you or your Ward, to receive payment of the care we provide, and for other health care operations. Healthcare operations generally include those activities we perform to improve the quality of care.
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Vaccine Questionnaire and Scheduling

GuidePoint COVID-19 Vaccine