Covid Booster Sign-up

Covid Booster Sign-up
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Which shot are you wanting today (All boosters going forward will be the bivalent vaccine)

1st Shot2nd ShotBooster
What vaccine did you receive originally?*

PfizerModernaJohnson & JohnsonFirst Shot
Which Vaccine would you like?*

Pfizer 12+Pfizer 5-11Pfizer 6 months to 4 yearsModerna 6 months through 17 yearsModerna 18+
Would you like a Flu shot at the same time as your booster?*

YesNo
Date of first dose

MonthDayYear
Date
Who administered your first dose
Medicap, Hy-vee, Public Health, out-of-state
Date of second dose

MonthDayYear
Date
Who administered your second dose
Medicap, Hy-vee, Public Health, out-of-state
Guthrie Appointment
Audubon Appointment
Have you had any of the following

Been receiving active cancer treatment for tumors or cancers of the bloodReceived an organ transplant and are taking medicine to suppress the immune systemReceived a stem cell transplant within the last 2 years or are taking medicine to suppress the immune systemModerate or sever primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich Syndrome)Advanced or untreated HIV infectionActive treatment with high-dose corticosteroids or other drugs that may suppress your immune responseNo