Monkeypox Virus (MPV) Vaccine Eligibility Form
Use the form below to determine whether or not you are eligible to receive the MPV vaccine (JYNNEOS) at this time. Eligible patients may use this form to request a vaccine appointment as well.
Are you residing (current CT resident), attending school, or stationed in Connecticut?
*
Yes
No
Have you had close personal contact in the past 14 days with someone diagnosed with a positive case of monkeypox? (this may include sexual partners, household contacts, and healthcare workers)
*
Yes
No
Do you meet at least one of the following criteria: Had a sexual partner in the past 6 months who was diagnosed with monkeypox; OR Had multiple sexual partners in the past 6 months in a jurisdiction (e.g., city/state/country) with known monkeypox; OR Have a current partner who has multiple sexual partners in a jurisdiction with known monkeypox; OR do you anticipate having a new sexual partner or partners in the next 6 months in a jurisdiction with known monkeypox.
*
Yes
No
Are you experiencing symptoms you believe may be due to monkeypox infection (ie. fever, headache, muscle aches and backache, swollen lymph nodes, chills, exhaustion and/or a rash) and/or have you ever been diagnosed with monkeypox?
*
Yes
No
Vaccination is not recommended for individuals with current monkeypox illness.
Persons with monkeypox symptoms who have had close personal contact with someone with known monkeypox in the past 14 days should contact their health care provider.
You are not eligible to receive the MPV vaccine in Connecticut at this time.
Continue to monitor guidance from your local health department and CT's Department of Public Health. Please visit their Monkeypox Webpage for the latest updates: https://portal.ct.gov/DPH/Epidemiology-and-Emerging-Infections/CT-Monkeypox/Monkeypox-Main-Information *If you are someone under 18 with a confirmed exposure please contact your local health department right away to be considered for the vaccine.*
You are eligible to receive the MPV vaccine at this time, you should especially consider getting vaccinated if:
Your partners are showing symptoms of monkeypox, such as a rash or sores. You met recent partners through online applications or social media platforms (such as Grindr, Tinder or Scruff), or at clubs, raves, sex parties, saunas or other large gatherings.You have a condition that may increase your risk for severe disease if infected with monkeypox virus, such as HIV or another condition that weakens your immune system, or you have a history of atopic dermatitis or eczema.
Eligible people can use the form below to request your MPV vaccine appointment at Circle Care Center in Norwalk.
Name
*
First Name
Middle Name
Last Name
Legal Name (If different from above)
First Name
Middle Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Birthdate
-
Month
-
Day
Year
Date
Are you currently a patient at Circle Care Center?
*
Yes, I am a current patient.
No, I am a new patient.
No, I am a returning patient.
Do you identify as any of the following? (select all that apply)
*
Gay
Bisexual
MSM (men who have sex with men)
Transgender
Gender Non-binary/Gender Non-conforming
None of the above
Have you already received your first dose of the JYNNEOS vaccine?
*
Yes, I am requesting my second dose.
No, I am requesting my first dose.
What days/times work best for you?
Please note that our clinical hours are Monday 9am - 7pm, Tuesday - Thursday, 9am - 5pm, Friday, 9am - 4pm.
Submit
Should be Empty: