Spanish (Latin America)
The following questions will help us determine if there is any reason you should not get the vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.
Date of Birth
Medicare Part B number
Skip if you don't have Medicare Part B
Last 4 digits of your social security number
Please enter a valid phone number.
Street Address Line 2
District of Columbia
Insurance card (if available), State ID or Driver's License
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Choose a file
Which vaccine(s) would you like to receive today?
Influenza (Flu shot)
Pneumococcal (pneumonia vaccine)
MMR (measles, mumps, and rubella)
Tdap (diphtheria, pertussis, and tetanus)
IPV (Polio vaccine)
Hepatitis B vaccine
Are you receiving a covid-19 vaccine today? If yes, which one?
Moderna covid-19 vaccine
What dose of Covid-19 vaccine are you recieving today?
Select which of the following applies to you,
Overwight or obesity
Long term (chronic) Kidney disease
Long term lung disease like COPD
A weakened immune system
Sickle cell disease
History of organ transplant
History of smoking
Substance use disorder
Select which of the following applies to you
First responder (healthcare workers, firefighters, police, congregate care staff)
Education staff (teachers, support staff, daycare worker)
Food and agriculture worker
U.S. Postal Service worker
Public transit worker
Grocery store worker
Are you feeling sick today?
For women only: Are you pregnant or Breastfeeding?
In the last 10 days, have you had a COVID19 test or been told by a healthcare provider or health department to isolate or quarantine at home due to a COVID19 infection or exposure?
Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days?
Have you had any vaccines in the past 14 days (2 weeks) including a flu shot?
Have you ever had any serious reaction to any vaccinations, including fainting and feeling dizzy?
Do you take cortisone, prednisone, other steroids, anticancer drugs, or have you had any radiation treatments?
Do you have any allergies to medications, food (e.g. eggs or egg products), latex, vaccines, or vaccine component?
Should be Empty: