COVID-19 Self Screening Eligibility Questionnaire V2

Calaveras Pharmacy COVID-19 Eligibility Screening
1. Have you received another vaccine (e.g., influenza) in the last 14 days? *

Yes No
2. Have you received antibody therapy (monoclonal antibodies or convalescent serum) to treat COVID-19 in the last 90 days? *

Yes No
3. Have you ever had an allergic reaction to: polysorbate, or a prior dose of the COVID-19 vaccine, or a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures? *

Yes No
You should not receive the COVID 19 vaccine within 14 days of another vaccine. Please schedule your COVID-19 vaccine after the 14-day period is over.
If you have been treated with antibody therapy (monoclonal antibodies or convalescent serum) for COVID-19, you should delay your COVID-19 vaccination until 90 days after the treatment was completed.
If you have had an allergic reaction to polysorbate, a prior dose of the COVID-19 vaccine, or a component of the COVID-19 vaccine, then you should not get the COVID-19 Vaccine. Consider discussing with your primary care physician or allergist.
Schedule your Johnson Vaccine appointment here.

Schedule your Moderna Vaccine appointment here.

Schedule your Pfizer Vaccine appointment here.
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Calaveras Pharmacy COVID-19 Eligibility Screening