COVID-19 Vaccine Appointment Scheduler and Registration Form
Pfizer Vaccination April 2 and April 23rd Fayetteville Town Center
Appointment Booking
Before booking your appointment, please confirm that you will be able to return on April 23rd to the Fayetteville Town Center, 15 W Mountain, to receive you second dose of the Pfizer COVID-19 vaccine:
*
I confirm that I am able to return on April 23rd.
I am unable to return on April 23rd.
Pfizer COVID Vaccine Dose #1 Appointment
*
First Name
*
Middle Initial
*
Last Name
*
Birth Date
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Race:
*
Asian
Black/African American
Native American/Alaska Native
Native Hawaiian/Other Pacific Islander
White
Other
Ethnicity:
*
Hispanic/Latino
Non-Hispanic
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
COVID-19 Vaccine Consent Form
Have you had a previous dose of COVID-19 vaccine?
*
Yes
No
Have you had any vaccines within the past 14 days? Pfizer-BioNTech or Moderna COVID-19 vaccine should be administered alone with a minimal interval of 14 days before or after any other vaccine.
*
Yes
No
Do you have a fever today?
*
Yes
No
Are you sick today?
*
Yes
No
Do you have COVID-19 infection and are currently in isolation?
*
Yes
No
Are you currently in quarantine for known exposure to someone with COVID-19?
*
Yes
No
Have you ever had a severe allergic reaction to any vaccine, vaccine component, or injectable therapy?
*
Yes
No
Are you allergic to polyethylene glycol? (A laxative)
*
Yes
No
Are you pregnant, breastfeeding, or planning on becoming pregnant?
*
Yes
No
Have you received monoclonal antibodies or convalescent plasma as treatment for a COVID-19 infection in the past 90 days?
*
Yes
No
I confirm that I am eligible to receive the COVID-19 vaccine in Arkansas based upon the current criteria as established by the Arkansas Department of Health.
*
Yes
No
I hereby declare that all the given information are accurate.
*
True
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Register
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform