Old Bivalent Signup/New RSV Message

Our FLU and RSV vaccines (Abrysvo for ages 60+) have arrived and we are taking walk-ins!

Come on down to Matt's Local Pharmacy-- we are currently accepting walk-ins for flu shots and RSV vaccines (you must be 60+ to receive the RSV vaccine).

We look forward to vaccinating you and your family! Stay safe and have a healthy winter.

--The team at MLP

Appointment*

Patient's full name*

FirstNameLastName

Last 4 digits of SSN*

4 digits

Name of accompanying adult if patient under 18/minor

First NameLast Name

Date of birth:*

DateofBirth

Gender assigned at birth:*

Address*

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

Street Address Line 2

CityState (example: RI, MA, CT)

Zip

Phone number*

Area CodePhone Number

Email

Please include your e-mail address, if you have one. This could allow you to locate your vaccination record on the state website and will allow us to send you an appointment confirmation.

Are you feeling sick today? (If yes, please delay vaccination until symptoms are resolved)*

No

Have you tested positive for COVID-19 within the last 14 days?*

NoYes- please return when you are fully recovered. The CDC recommends waiting 90 days after a covid-19 infection to receive your booster.

Are you over the age of 65, or under the age of 65 but are immunocompromised?*

Yes- I am 65 years or above, and I received my last covid-19 vaccine at least 4 months ago.Yes- I am an immunocompromised individual and I received my last covid-19 vaccine at least 2 months ago.No- if the above options do not apply, you are not currently eligible for another bivalent covid-19 vaccine.

Please enter the date you received your last covid-19 vaccine

Date

Which vaccine will you be receiving with us?*

Pfizer bivalent boosterModerna bivalent booster

Have you had a serious allergic reaction to any foods, medications, vaccinations, or latex? (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.)*

NoYes- please inform us during check-in, and plan to remain on-site for the required 30 minutes for monitoring (can wait in your vehicle if accompanied by another adult)

Do you have a bleeding disorder or take blood thinners such as Warfarin/Coumadin?*

NoYes

Have you received or are you receiving HCT or CAR-T-cell therapy?*

NoYes- if you received doses of COVID-19 vaccine prior to or during HCT or CAR-T cell therapy, you should be revaccinated for any doses received before or during treatment at least 3 months (12 weeks) after transplant or CAR-T-cell therapy. Please call your healthcare provider or the pharmacy to discuss your vaccination schedule.

Do you have a history of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining around the heart) either related to or unrelated to receipt of an mRNA COVID-19 vaccine?*

NoYes- please consult with your healthcare provider and return after your episode of myocarditis or pericarditis has resolved.

Are you moderately/severely immunocompromised from a medical condition/immunosuppressive therapy, including/not limited to: active treatment for solid tumor/hematologic malignancy, solid organ/stem-cell transplant, primary immunodeficiency syndrome, advanced/untreated HIV infection, or active treatment with high dose corticosteroids/other immunosuppressive/ immunomodulatory biologic agents?*

NoYes- please confirm with your healthcare provider that you are eligible for the new covid-19 booster.

Are you currently receiving immunosuppressive therapies? (i.e. Humira®, Remicade®, etc.)*

NoYes- COVID-19 vaccines should be administered at least 2 weeks before initiation or resumption of immunosuppressive therapies. Please review timing of your immunosuppressive therapy before receiving your booster.

Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)?*

NoYes- please discuss your eligibility with your healthcare provider before vaccination.

Do you have a history of thrombosis with thrombocytopenia syndrome (TTS) following the Janssen COVID-19 vaccine or any other adenovirus-vectored COVID-19 vaccines (e.g., AstraZeneca's COVID-19 vaccine)?*

NoYes- you may receive the pfizer or moderna bivalent booster once your clinical condition has stabilized.

Have you received a vaccine for Orthopoxvirus (Monkeypox vaccine) in the last 4 weeks?*

NoYes- it is recommended to wait at least 4 weeks after receiving the monkeypox vaccine before receiving your covid-19 booster.

Signature of patient/guardian who completed application*

Sign with finger if using smart phone/ mouse if on computer

Are you interested in receiving a shingles vaccine or pneumonia vaccine during your visit with us? It is safe to receive multiple vaccines in the same visit, and the shingles and pneumonia vaccine are both recommended in patients over 65.

Yes- let us know at check-in!Not today.