COVID-19 Vaccine Appointment Form: **Pfizer ONLY, age 12 and older**

Pfizer Appointment *

Please indicate if this is your First dose, Second dose, First Booster, Second Booster (**Limited eligibility). Please see updated guidance and references at bottom of this page *

First Dose Second Dose Booster #1 (**See link to CDC guidelines below) Booster #2 (Limited Eligibility *See guidelines below)

First Appointment Date

Date

Second dose of Pfizer can be scheduled three weeks (21 days) after your first dose. Booster dose #1 Pfizer can be scheduled 5 months after the completion of your primary series in patients 12 years of age and older. Please reference https://www.cdc.gov/vaccines/covid-19/downloads/summary-interim-clinical-considerations.pdf to see if you are eligible and make sure to read all information on this link.

The summary of recent changes from CDC clinical considerations regarding second Booster:

Summary of recent changes (last updated April 21,2022):
Added guidance that people ages 12 years and older who are moderately or severely immunocompromised may choose to receive a second booster dose using an mRNA COVID-19 vaccine at least 4 months after the first booster dose
Added guidance that adults ages 50 years and older who are not moderately or severely immunocompromised may choose to receive a second booster dose using an mRNA COVID-19 vaccine at least 4 months after the first booster dose. Click on links below to reference.

https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html#second-booster

https://www.cdc.gov/vaccines/covid-19/downloads/Clinical-Considerations-Second-COVID-19-Booster-508.pdf

*Please consult your doctor or health care provider if you have any questions about vaccine eligibility and current CDC recommendations.*

Name *

First Name Middle Initial Last Name

Email *

example@example.com

Phone Number *

Please enter a valid phone number.

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Date of Birth *

Date

What is your gender assigned to birth? *

What is your ethnicity? *

Do you have any allergies to medications, insects, food, or vaccine components? *

No Yes (what are you allergic to and what was your reaction?)

Do you have insurance? (If yes, please upload a picture of front and back of insurance card below. If no, please upload a picture of your driver's license.) *

Yes No

Please upload image of your insurance card or driver's license here.

Please print and complete this consent and screening form prior to appointment.

Select which dose you plan on receiving: (Please bring your CDC Vaccination Record Card **PFIZER ONLY available**) *

1st dose 2nd dose First Booster Second Booster

COVID-19 Vaccine Appointment Form: Pfizer ONLY, age 12 and older

Questionnaire

IF UNDER 18, MUST BE ACCOMPANIED BY A PARENT OR GUARDIAN.