Feb 2023 Forsyth Pfizer COVID-19 Booster Vaccine Scheduling- Patagonia

Pfizer COVID-19 Booster

Please note: The goal of this form is to know if you can get a booster of the Pfizer-BioNTech COVID-19 Vaccine, Bivalent (Original and Omicron BA.4/BA.5).

To get your booster, you must have had 2 primary doses of the Pfizer or Moderna vaccine, or any booster dose at least 2 months ago. For Johnson & Johnson, you must have had at least 1 dose at least 2 months ago.

IMPORTANT - Please Read: If you choose an appointment date less than 2 months from your 2nd Pfizer or Moderna COVID-19 dose, or 2 months from your first Johnson & Johnson COVID-19 vaccine, you will NOT be able to receive the booster on that date.

If you are 16 or older and moderately to severely immunocompromised, and looking to get your 3rd dose of Pfizer COVID-19 vaccine:

1) and it has been at least 28 days since your last Pfizer COVID-19 vaccine

2) Please call (417) 334-4544 x577 to schedule an appointment

Are you age 18 or older?*

YesNo

Are you age 12 or older?*

YesNo

Name of Parent/Legal Guardian (if under 18)*

Currently, due to state orders, you must be 12 or older and meet certain criteria to receive the Pfizer booster.

If you are age 16 -17, and moderately to severely immunocompromised, please call (417) 334-4544 x577 to make an appointment.

The next section asks about your reason(s) for getting the Pfizer booster.

Definitions for some of those reasons can be found by clicking this link from the CDC (the link will open in a new window).

People with Certain Medical Conditions

Reason for getting a booster of the Pfizer Vaccine (check all that apply):*

Currently, due to Missouri DHSS orders, you must be 12 or older and meet certain criteria to receive the Pfizer COVID-19 booster vaccine. Based on your response you do not qualify at this time. We will update our scheduling links as DHSS orders are updated.

Do you know where your COVID-19 Vaccination Record Card is?*

YesNo

Please Note: It is important that you have your COVID-19 Vaccination Record Card so that we can verify your eligibility to receive the Pfizer COVID-19 booster vaccine. If you do not know where your card is, please contact the facility where you were vaccinated to obtain a record of your COVID-19 Vaccination(s), then return to this page to register.

Please note: It is important that you bring your COVID-19 Vaccination Record Card with you to your appointment. This is so we can check if you are able to receive the Pfizer booster.

How many doses of the COVID-19 vaccine have you received?*

One Dose of Pfizer or ModernaTwo Doses of Pfizer or ModernaThree or more Doses of Pfizer or ModernaOne or more Doses of Johnson & JohnsonNone of the above

Which vaccine did you receive?*

PfizerModerna

Enter your LAST COVID vaccination date*

Date

LCV Month

LCV Day

LCV Year

Maximum LCV Date

Date

Maximum 3 Dose LCV Date

Date

Maximum JnJ LCV Date

Date

Unfortunately, we have no upcoming clinics that meet your eligibility at this time. Please continue to check back as this tool will be updated often.

First Name*

Middle Initial

Last Name*

Date of Birth*

Date

Today

Date

Difference in Days Calculation

Difference in Years Calculation

Minor Selection Options*

Since you have not received your 1st and 2nd doses of Pfizer or Moderna COVID-19 vaccine, or 1 dose of the Johnson & Johnson COVI-19 vaccine, you are not currently eliigible for the COVID-19 booster. Please contact the Taney County Health Department at (417) 334-4544 x577 to discuss your COVID-19 vaccine options.

Health History*

	Yes	No	Unknown
1. Are you feeling moderately or severely ill today? Mild illnesses or taking antibiotics are not reasons for withholding a vaccination.
2. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine or Epi Pen or for which you had to go to the hospital?
3. Have you ever had a serious reaction after any vaccination or injectable medication, including a previous dose of the COVID-19 vaccine?
4. In the past 14 days have you tested positive for COVID-19 or had contact with a lab confirmed COVID-19 patient?
5. Are you breastfeeding or pregnant?
6. Have you ever had an allergic reaction (e.g. anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.
7. Are you immunocompromised? (taking medication or being treated for cancer, leukemia, HIV/AIDS or other immune system problems or taking medication that affects your immune system)
8. Do you have a bleeding disorder or are you taking a blood thinner?
9. Have you ever received a dose of COVID-19 vaccine?
10. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
11. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
12. Have you been diagnosed with an immune mediated syndrome characterized by thrombosis and thrombocytopenia or Heparin Induced Thrombocytopenia (HIT)?
13. Do you have dermal fillers?
14. Do you have or have a history of Multisystem Inflammatory Syndrome in Children or Adults (MIS-C or MIS-A)?

Agency

Agency Address

Clinic Admin Address

Lot Number

Manufacturer

Brand

Exp Date

Date Administered

Fact Sheet date

EUA Given Date

Dose number

123

This form is for the Pfizer booster. If you're looking for boosters for Moderna, or Johnson & Johnson, please visit our website for other options.

ClinicSchedulingText

Month Plus 8

Pfizer booster Vaccination Authorization Date

Please make note of the Eligibility date below. After pressing the Submit button, click the link on the Next page to schedule your Pfizer booster. IMPORTANT: When scheduling, make sure you select a date that is on or after the Eligibility date shown below.

Eligible Month

Eligible Day

Eligible Year

PLEASE READ: By signing below, you consent to the disclosure of the health and personal information you provide to the State of Missouri ShowMeVax registry and/or health care providers for the purpose of scheduling vaccination.

Signature*

Clear

Forsyth Pfizer COVID-19 Booster Vaccine Scheduling and Consent

Demographic Information

Health History