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

COVID-19 VACCINE / INFLUENZA VACCINE APPOINTMENT FORM

Vaccines are given at Village Walk Pharmacy
Pfizer Appointment*
Please reference the CDC website for more information on how to stay up to date with COVID vaccines.

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html

Per the CDC Clinical Guidance for COVID-19 Vaccines:

People ages 65 years and older are recommended to receive 1 dose of updated (2023–2024 Formula) mRNA vaccine; an additional dose of COVID-19 vaccine is not recommended at this time. ACIP will continue to evaluate available data on the epidemiology of COVID-19 and the safety and effectiveness of COVID-19 vaccines. Based on these assessments, ACIP will update COVID-19 vaccine policy and guidance as needed, especially for people at increased risk for severe COVID-19, including people ages 65 years and older.

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

*Please consult your doctor or health care provider if you have any questions about vaccine eligibility and current CDC recommendations.*
Date of last COVID-19 Vaccine ( eligible for 2023-2024 formulation at least 8 weeks after last dose)

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Questionnaire
Date of Birth*

MonthDayYear
Date
What is your gender assigned to birth?*
What is your ethnicity?*
Do you have any allergies to medications, insects, food, or vaccine components?*

NoYes (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.)*

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

Cancelof
Please print and complete this consent and screening form prior to appointment.
IF UNDER 18, MUST BE ACCOMPANIED BY A PARENT OR GUARDIAN.
Should be Empty:

COVID-19 VACCINE / INFLUENZA VACCINE APPOINTMENT FORM

Questionnaire

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