COVID Immunization Schedule Form

COVID-19 Vaccine Scheduling Tool

Thank you for using our online tool for scheduling your COVID-19 vaccine. All vaccinations are currently taking place at 301 W. Alder St. in downtown Missoula. Please fill out the webform below to schedule your vaccination. Additional clinic days will continually be opened into the future as we monitor demand. If none of the available times work for your schedule, feel free to call 406-258-3363, leave a detailed voicemail and we'll call back as soon as we can. Thank you for your patience during this period in which our team is extrememly busy serving the needs of our community.
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *

Month Day Year
Date
Phone Number *
Please enter a valid phone number.
Email (only used to send an appointment reminder)
example@example.com
What brand of vaccine are you requesting? *

Pfizer Moderna Johnson & Johnson (Janssen) Other (Will discuss with Public Health Nurse at appointment)
Which dose are you requesting? *

Primary Series 1st Booster Dose 2nd Booster Dose
Are you 50 years of age or older?

Yes No
Do you have a severely or morderately immunocompromising health condition?

Yes No
Per CDC and FDA guidlelines, 2nd COVID-19 boosters are only authorized for individuals 50 years of age and older OR for individuals with severely or moderately immunocompromising conditions. If you do not meet these requirements, we are not able to offer you a 2nd booster without a written prescritpion from your physician. Please speak with your healthcare provider (prescription can be faxed to 406-258-4913) and call us at 406-258-3363 to schedule your appointment after we have received the prescription.
Covid-19 Vaccine Group Appointment *
Thak you for completing the following CDC-required screening questions. This will speed up the process while you are in our clinic and allow us to serve more clients in a timely manner:
Have you ever received a dose of Covid-19 vaccine previously (leave blank if no). If so, which product(s) did you receive?

Pfizer-BioNTech Moderna Janssen (Johnson & Johnson) Other
How many doses of COVID-19 vaccine have you received?
Do you have a health condition or are you undergoing treatment that makes you moderately or severely immunocompromised?

Yes No Don't Know
Have you received hematopoietic cell transplant (HCT) or CAR-T-cell therapies since receiving COVID-19 vaccine?

Yes No Don't Know
Have you ever had an allergic reaction to Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?

Yes No Don't Know
Have you ever had an allergic reaction to Polysorbate, which is found in some vaccines, film-coated tablets, and intravenous steroids?

Yes No Don't Know
Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?

Yes No Don't Know
Have you ever had an allergic reaction to another vaccine (other than COVID-19) or an injectable medication?

Yes No Don't Know
Check all that apply to you:

Am a female between ages 18 and 49 years old Am a male between ages 12 and 29 yeras 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-Barre Syndrome (GBS) None of the Above
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

COVID-19 Vaccine Scheduling Tool