Pfizer 12 years and older COVID-19 Vaccine Signup

1
Have you ever had an allergic reaction to a previous dose of COVID-19 vaccine or a component of a COVID-19 vaccine? This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.* This field is required.
YESNO
2
We are sorry but you are not eligible to receive the COVID-19 vaccine because of your allergy. We recommend you contact your primary care physician for further guidance. You may leave this page.
3
Which dose are you scheduling?* This field is required.
First dose
Second dose
Third dose
Fourth dose
4
Does the patient have a health condition or are they undergoing treatment that makes them moderately or severely immunocompromised? (This would include, but not be limited to, treatment for cancer, HIV, receipt of organ transplant, immunosuppressive therapy or high-dose corticosteroids, CAR-T-cell therapy, hematopoetic cell transplant (HCT), or moderate or severe primary immunodeficiency.)
YESNO
5
Is the patient 50 years old or older?
YESNO
6
We are sorry but a fourth dose is only recommended for people who are 50 years or older or who are immunocompromised, so this patient is not eligible at this time. You may leave this page.
7
Has the patient received COVID-19 vaccine before or during hematopoietic cell transplant (CHT) or CAR-T-cell therapies?
YESNO
8
COVID-19 vaccination is not recommended until 12 weeks after transplant or CAR-T-cell therapy. If it has been less than 12 weeks since the patient's treatment, please do not schedule your appointment at this time. Otherwise you may continue to schedule.
9
Were all previous doses given at Mesquite Pediatrics* This field is required.
YESNO
10
What was the date of the first dose?* This field is required.
Date
Year
Month
Day
11
What was the date of the second dose?* This field is required.
Date
Year
Month
Day
12
What was the date of the third dose?* This field is required.
Date
Year
Month
Day
13
The second dose should be at least 3 weeks after the first dose. Please choose a date with that in mind.
14
For most people, the third dose should be at least 5 months after the second dose. For those who are immunocompromised, the third dose should be at least 4 weeks after the second dose. Please choose a date with that in mind.
15
The fourth dose for immunocompromised people should be at least 3 months after the third dose. For people 50 years or older who are not immunocompromised, it should be at least 4 months after the third dose. Please choose a date with that in mind.
16
Select an appointment date and time. The second dose should be at least 3 weeks after the first dose and the third dose should be at least 5 months after the second dose.* This field is required.
17
Name of person getting vaccine* This field is required.
First Name
Last Name
18
Parent/Guardian's Name (if applicable)
First Name
Last Name
19
Date of Birth* This field is required.
Date
Month
Day
Year
20
Email* This field is required.
example@example.com
Confirm Email
21
Phone Number* This field is required.
Please enter a valid phone number.
22
Is the patient a registered patient of Mesquite Pediatrics?* This field is required.
YESNO
23
Sex* This field is required.
Female
Male
24
Has your address changed since the last time you were seen at Mesquite Pediatrics?* This field is required.
YESNO
25
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
26
Has your insurance changed since the last time you were seen at Mesquite Pediatrics?* This field is required.
YESNO
27
Does the patient have Health Insurance?* This field is required.
Private Insurance
Medicaid/AHCCCS
Medicare
No insurance
28
Name of Insurance Company or AHCCCS Plan* This field is required.
29
Subscriber ID/Policy Number* This field is required.
30
PO Box for Medical Claims (just the PO Box number)* This field is required.
(usually on the back of the card)
31
Medicare ID Number or Social Security Number* This field is required.
32
Social Security Number* This field is required.
Driver's license number if SSN not available
33
We are sorry but as of April the government has stopped funding the
vaccine for people without insurance so we cannot offer you the vaccine
at this time. Please go to
https://webcms.pima.gov/cms/One.aspx?portalId=169&pageId=669257 to
see other locations in Pima County where the vaccine may be available.
34
I hereby assign to Mesquite Pediatrics any insurance or other third-party benefits available for the administration fee of the COVID-19 vaccine provided to my child. I agree to forward to Mesquite Pediatrics all health insurance and other third-party payments I receive for services rendered to my child immediately upon receipt. I agree to allow the health care provider to release information to the Arizona State Immunization Information System (ASIIS) to record that my child has received the COVID-19 vaccine. This information will help keep track of the manufacturer and doses of the vaccine. I have had a copy of the Emergency Use Authorization for the COVID-19 vaccine made available to me (https://www.fda.gov/media/153717/download). I have had a chance to ask questions and I believe I understand the benefits and risks of the COVID-19 vaccines requested. I ask that the vaccines be administered to my child.* This field is required.
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