• Those 12 years and up CAN get a COVID-19 booster dose through this form. This form is NOT for scheduling COVID-19 primary series vaccines or for booster doses younger than 12 at this time.

  • Cabrini University Flu & COVID-19 Vaccine Clinic Registration Form

    This scheduling and consent form is for Cabrini University. The clinic will be held on 11/01/2022 from 12:00pm – 3:00pm.

  • Patient Information

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  • An updated booster dose is recommended at least 2 months after the date of your last dose. Your last dose can be the final dose of the primary series or a previously authorized booster dose.
  • You are not eligible for a bivalent booster vaccine at this time.
  • You are not eligible for this vaccine.
  • You are not eligible for this manufacturer's vaccine at this time.

  • We do not have that vaccine at this time.

  • Please contact the pharmacy to review eligibility for this vaccine.

  • Questionnaire

  • Signatures

  • Pfizer (12+) VIS Moderna (12+) EUA Flu Injection VIS Flu Mist VIS Other Vaccine Information Statements can be found by clicking here   Notice of Privacy Practices
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  • After submitting, you will be redirected to schedule your appointment. Please make sure to confirm your appointment so we save your spot on our schedule. If you are scheduling for COVID-19 and another vaccine, please only make the COVID-19 appointment. If there are no appointments available for the vaccine you need, please check back.

  • PLEASE PRINT

    BEFORE YOU CLICK SUBMIT, PLEASE FOLLOW THE STEPS BELOW:

    1. Click the "Preview PDF" button below.
    2. Print your form by clicking the printer icon (top right of your screen). Note: You can only print if your device is connected to a printer.
    3. Click "Back to Form" (top left of your screen).
    4. Click "Submit"
    5. Bring your form, COVID-19 vaccination card, ID, and inusurance card to the clinic.
  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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