Vaccine Appointment Scheduling/ Screening Checklist and Consent Form
246 Bowdoin St. Dorchester, MA 02122 Tel: (617) 322-9265
Appointment
*
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Unknown
Race
*
American Indian or Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Black or African American
White
Other
Ethnicity
*
Hispanic
Not Hispanic or Latino
Unknown
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Allergies
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Primary Care Physician (PCP) Name
First Name
Last Name
PCP Phone Number
Please enter a valid phone number.
Insurance information
*
Name and ID
Screening Questions:
1. Are you feeling sick today?
*
Yes
No
Don't know
2. Which vaccine are you looking for today?
*
Flu
COVID-19
Shingles
Tdap
Pneumonia
Other
3. Do you have allergies to medications, food, a vaccine component, or latex?
*
Yes
No
Don't know
4. Have you ever had a severe allergic reaction after receiving a vaccine or an injectable medication?
*
Yes
No
Don't Know
5. Have you received any vaccine in the past 4 weeks?
*
Yes
No
Don't Know
6. Do you have any of the following: a long-term health problem with heart, lung, kidney, or metabolic disease (e.g, diabetes), asthma, a blood disorder, no spleen, a cochlear implant, or a spinal fluid leak?
*
Yes
No
Don't Know
7. Do you have a bleeding disorder or are you taking blood thinner?
*
Yes
No
Don't Know
8. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
*
Yes
No
Don't Know
9. Have you received monoclonal antibodies or convalescent serum as treatment for COVID-19 in the past 90 days?
*
Yes
No
Don't Know
10. In the past 6 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you had radiation treatments?
*
Yes
No
Don't Know
11. Have you had a seizure or a brain or other nervous system problem?
*
Yes
No
Don't Know
12. Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem inflammatory syndrome (MIS--A or MIS-C) after an infection with the virus that causes COVID-19?
*
Yes
No
Don't Know
13. For women: Are you pregnant or breastfeeding?
*
Yes
No
Don't Know
14. Have you ever felt dizzy or faint before, during, or after a shot?
*
Yes
No
Don't Know
Are you 18 years and younger
*
Yes
No
Signature of person to receive vaccine & EUA/VIS
*
Name of parent, guardian, or authorized representative
First Name
Last Name
Signature of parent, guardian, or authorized representative
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: