Senior COVID-19 Vaccine Waitlist

Date*

Date

Hour Minutes

Name of person completing this form*

First NameLast Name

Consent

The Office for the Aging Call Center is for clients 60 years and over. Are you at least 60 years old? Note: If you are not 60 years old or older, you may not register at this time.

Yes

Are you a Rockland County resident*

YesNo

Currently, there are no vaccination appointments available with the County. Would you be interested in putting your name on an appointment waitlist? The calls are recorded in the order which they are received. Once an appointment becomes available, the Call Center Team will contact you should an opportunity arise to assist with making an appointment for you.

Office for the Aging needs your consent to be placed into our electronic database, do we have your consent?

Yes

Do you consent to answering medical questions that the appointment registration requires?

Yes

Personal Information

Name*

First NameLast Name

Date of birth*

Date

Address*

Street Address

Street Address Line 2

City

Zip Code

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Do you want an appointment within Rockland County only?*

YesNo

Is this your first or second dose?*

FirstSecond

THIS SECTION FOR CALL CENTER STAFF ONLY

CALL CENTER STAFF: You may be eligible to receive your second dose of the COVID-19 vaccine at Rockland Community College. Please go to www.ny.gov, scroll down to COVID-19 and click, Am I Eligible, and this will give you a list of all of the eligible state vaccination centers. Click on Rockland Community College and begin registering the client for the appointment.

Do you have a vaccine preference?*

ModernaPfizer-BioNtechJohnson & JohnsonNo preference

Do you have a vaccine preference?

ModernaPfizer-BioNtechJohnson & JohnsonNo preference

Medical Information

Have you ever been treated with antibody therapy or convalescent plasma for Covid-19 in the last 90 days?*

YesNo

Have you ever had an immediate allergic reaction (e.g. hives, facial swelling, difficulty breathing, anaphylaxis) to any vaccine, injection, or shot or to any component of the COVID-19 vaccine, or a severe allergic reaction (anaphylaxis) to anything?*

YesNo

Have you had any vaccines in the past 14 days including the flu shot?*

YesNo

Do you have a bleeding disorder or are you currently taking a blood thinner?*

YesNo

Do you have cancer, leukemia, HIV/AIDS, a history of autoimmune disease or any other condition that weakens the immune system?*

YesNo

Do you take any medication that may affect your immune system, such as cortisone, prednisone or other steroids, anticancer drugs, or have you had any radiation treatments?*

YesNo

Have you ever received a dose of the COVID-19 vaccine?*

YesNo

Appointment Information

Appointment Date

Date

Hour MinutesAM/PM Option

Location

Confirmed with Patient

YesNo

Email Appointment Information

Email My Confirmation Number (You must provide an email address in the email field above)