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Pediatric COVID-19 Bivalent Booster- Ages 3-11
- Patients must be between ages 3 and 11
- The following vaccine options are available: pfizer bivalent booster (ages 3-4), pfizer bivalent booster (ages 5-11), moderna bivalent booster (ages 6-11)
- If receiving a booster dose, your child is required to have completed the primary series or their last booster at least 2 months ago. Please bring their vaccination card to the appointment
- Please arrive within 15 minutes of your designated reservation time and be prepared to wait as we check in each child :)
***NOTE: Please indicate on the form below if you would prefer vaccination in-vehicle. Please call pharmacy phone (401-619-5020) when you arrive and we will send an immunizer out to your family as soon as possible. Please prepare for a short wait and to remain on-site (in vehicle) for 15 minutes after vaccination.
Please note:

Due to high demand and the nature of pediatric vaccinations, please allow a potential wait time up to 15 minutes upon arrival. The pediatric formulations need to be individually mixed before the immunization. We know vaccinations can be scary– our goal is to make the immunization experience as comfortable as possible for your family. We thank you for your patience as we get these kiddos vaccinated! :) -The team at MLP
Appointment*
Basic Demographic Information
Patient's Full Name*

First Name Last Name
Date of Birth:*

MonthDay Year
Date
Gender:*
Address*

Physical/Street Address (P.O. Box is NOT accepted)

Street Address Line 2

City State / Province

Zip
Phone Number*

Area Code Phone Number
Email*
example@example.com
Name of adult accompanying child:*

First Name Last Name
Health Insurance Information

This information can be found on insurance card. Please help us by providing this information if your child has prescription insurance. Thank you!
Does your child have active prescription insurance?*

YesNo insurance
Rx BIN
Rx PCN
Rx Group
Member ID
Immunization Screening Questionnaire
Is your child between ages 3-11?*

Yes, they are between ages 3-11.No- please do not complete the registration process at this time, as your child is not eligible to receive the pediatric formulation of this vaccine.
Which vaccine will your child be receiving today?*

Pfizer bivalent booster (ages 3-4)Pfizer bivalent booster (ages 5-11)Moderna bivalent booster (ages 6-11)
Would you like your child to be vaccinated in your vehicle? **NOTE: children with a history of anaphylactic reactions must be vaccinated in the building and must be monitored for 30 minutes afterwards*

YesNo
I acknowledge that it has been at least 2 months since my child received their last covid vaccine*

YesNo- please return at a later date.
Is your child currently sick, for example: are they currently experiencing fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, etc.? (If you answer yes, please delay vaccination until symptoms are resolved)*

NoYes- please return at a later date.
Has your child had a severe allergic reaction (e.g. anaphylaxis, throat closing, trouble breathing) to any component of a COVID-19 vaccine, including lipid nanoparticle or polyethylene glycol (PEG)? If you answer yes, please do not complete the registration process as the patient is not eligible to receive the vaccine at this time. Please follow up with your pediatrician.*

NoYes
Has your child had a severe allergic reaction (e.g. anaphylaxis, throat closing, trouble breathing) with any vaccine or injectable therapy, or a history of anaphylaxis due to any cause (food, medication, etc.)? Please notify the pharmacy staff if answering "yes"*

NoYes- please notify pharmacy staff on arrival.
Has your child tested positive for COVID-19 in the last 10 days? (if you answer yes to this question, please do not complete the registration process as your child is not eligible to receive the vaccine at this time)*

NoYes- please return at a later date.
Are you (parent/ guardian/caregiver) or your child currently in quarantine for COVID-19 exposure? (if you answer yes to this question, please do not complete the registration process as your child is not eligible to receive the vaccine at this time)*

NoYes- please return at a later date.
Does your child have a medical condition or are they receiving treatments that are associated with moderate to severe immune compromise? (e.g. solid organ transplant recipients or those who are diagnosed with conditions that are considered to have an equivalent level of immunocompromised)*

NoYes- please notify pharmacy staff on arrival.
Has your child been diagnosed with Multisystem Inflammatory Syndrome in the last 90 days? (If you answer yes to this question, please consult with your pediatrician prior to receiving the COVID-19 vaccine)*

NoYes
Signature of patient/guardian who completed application*

Sign with finger if using smart phone/ mouse if on computer Clear
Should be Empty:

Please note:

Basic Demographic Information

Health Insurance Information

Immunization Screening Questionnaire