Pfizer BOOSTER (bivalent) COVID-19 Immunization Appointment Scheduling

Pfizer UPDATED BOOSTER (bivalent) COVID-19 Immunization Scheduling Form
-The Pfizer boosters Donlon's have are approved for patients age 12 and older. It must be at least 2 months since last COVID-19 vaccine. If you would like a booster for age 6-11, please see Moderna scheduling link on Donlonrx.com

-If you have already received a BIVALENT booster, you are not eligible for another dose at this time.

-Bring your ID, insurance cards (if you have them) and COVID vaccine card to appointment

-The CDC/FDA has approved "mixing and matching" of COVID-19 vaccines. If you desire the Pfizer booster, see other scheduling link on Donlonrx.com
Please indicate the last date you received a COVID-19 vaccine. The bi-valent COVID vaccine can be given at least 2 months after the last COVID-19 dose (either 2nd dose or booster dose). If you have already received a BIVALENT booster, you are not eligible for another dose at this time.*

MonthDay Year
Date
Would you also like a flu vaccine during this appointment? Donlon's has the Afluria quadrivalent vaccine on hand. Donlon's is OUT of the flu vaccine for ages 65+, but if over 65, you can choose to receive the Afluria vaccine. Call the pharmacy with questions.*

YesNo
COVID-19 Vaccination Appointment

Please keep your appointment or call the pharmacy if you need to cancel or change it.
Please select an available appointment (date and time) to receive your COVID-19 vaccine.*
Patient Information
Patient Name*

First Name Middle Name Last Name
Date of Birth*

MonthDay Year
Date
Gender*

FemaleMale
Patient Phone Number*
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Race/Ethnicity:

CaucasianAfrican AmericanHispanicAsianAmerican IndianPacific IslanderOther
Please select the preferred administration site to receive your COVID vaccine.*

Left ArmRight Arm
Please select the preferred administration site to receive your flu vaccine.*

Left ArmRight Arm
Should be Empty:

Pfizer UPDATED BOOSTER (bivalent) COVID-19 Immunization Scheduling Form

COVID-19 Vaccination Appointment

Patient Information