Covid Booster Sign-up
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Which shot are you wanting today (All boosters going forward will be the bivalent vaccine)
1st Shot
2nd Shot
Booster
What vaccine did you receive originally?
*
Pfizer
Moderna
Johnson & Johnson
First Shot
Which Vaccine would you like?
*
Pfizer 12+
Pfizer 5-11
Pfizer 6 months to 4 years
Moderna 6 months through 17 years
Moderna 18+
Would you like a Flu shot at the same time as your booster?
*
Yes
No
Date of first dose
-
Month
-
Day
Year
Date
Who administered your first dose
Medicap, Hy-vee, Public Health, out-of-state
Date of second dose
-
Month
-
Day
Year
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 blood
Received an organ transplant and are taking medicine to suppress the immune system
Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system
Moderate or sever primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich Syndrome)
Advanced or untreated HIV infection
Active treatment with high-dose corticosteroids or other drugs that may suppress your immune response
No
Submit
For office use only
Notes
Panora Appointment
Guthrie Center Appointment 10/27
Casey Appointment
Stuart Appointment
Should be Empty: