Mpox vaccine registration

1

How did you hear about this service?

An organization I receive services from

My employer

TV

Radio

Billboard

Social media

Flyer

Friend/family member

Springfield-Greene County Health website

Phone call or text messages

Community Health Advocate

2

Who is filling out this form?* This field is required.

I am the patient

I am the patient's legal representative

Vaccine Nurse (For Internal Use Only)

3

What is your relationship to this patient?* This field is required.

4

Your name

5

Do you need your first or second Mpox vaccine?* This field is required.This is a two-dose vaccine.

First dose

Second dose

Unsure

6

Patient's full name* This field is required.

First Name

Middle Name

Last Name

7

Date

8

Date of birth* This field is required.

Date

9

Age

10

PH/MRN number* This field is required.If this is a new patient, please back up and use the I am a patient.

11

What is your preferred method of contact?* This field is required.A staff member from Springfield-Greene County Health will contact you to schedule your vaccine appointment.

Phone

Email

12

Email* This field is required.

example@example.com

13

Primary phone number* This field is required.

14

Last 4 digits of Social Security Number* This field is required.

15

Address* This field is required.

Street Address

City

Postal / Zip Code

Country

16

Where does the patient currently reside?* This field is required.The Shingles vaccine is available at no charge to any Greene County resident age 60 years or older, thanks to a grant from the Greene County Senior Citizens' Services Fund Board.

Within Springfield city limits

Outside of Greene County

Greene County

17

Patient's race* This field is required.Please select all that apply. We are asking you these questions in order to provide more patient-centered care and to better understand the populations we are serving. Your answers are confidential and protected by law, just like all of your other health information.

American Indian/Alaska Native

Asian

Black/African American

Pacific Islander

White

Decline to respond

Other

18

Patient's ethnicity* This field is required.We are asking you these questions in order to provide more patient-centered care and to better understand the populations we are serving. Your answers are confidential and protected by law, just like all of your other health information.

Hispanic/Latinx

Not Hispanic/Latinx

Decline to respond

19

What is the patient's preferred language?* This field is required.We are asking you these questions in order to provide more patient-centered care and to better understand the populations we are serving. Your answers are confidential and protected by law, just like all of your other health information.

20

Patient's sex assigned at birth* This field is required.We are asking you these questions in order to provide more patient-centered care and to better understand the populations we are serving. Your answers are confidential and protected by law, just like all of your other health information.

Male

Female

Decline to respond

21

Patient's current gender identity* This field is required.We are asking you these questions in order to provide more patient-centered care and to better understand the populations we are serving. Your answers are confidential and protected by law, just like all of your other health information.

Male

Female

Transgender male

Transgender female

Genderqueer

Decline to respond

22

Patient's gender pronouns* This field is required.We are asking you these questions in order to provide more patient-centered care and to better understand the populations we are serving. Your answers are confidential and protected by law, just like all of your other health information.

She/Her

He/Him

They/Them

Decline to respond

Other

23

Patient's sexual orientation* This field is required.We are asking you these questions in order to provide more patient-centered care and to better understand the populations we are serving. Your answers are confidential and protected by law, just like all of your other health information.

Bisexual

Straight or Heterosexual

Lesbian, Gay or Homosexual

Unsure or questioning

Decline to respond

Other

24

Patient's insurance status* This field is required.We are asking you these questions in order to provide more patient-centered care and to better understand the populations we are serving. Your answers are confidential and protected by law, just like all of your other health information.

Private or Employer Insurance

Medicare

Medicaid

Underinsured

Uninsured

Decline to respond

25

At this time is the patient unsheltered or homeless?* This field is required.We are asking you these questions in order to provide more patient-centered care and to better understand the populations we are serving. Your answers are confidential and protected by law, just like all of your other health information.

YESNO

26

Are you feeling sick today, or have you had a fever in the past two days?* This field is required.

Yes

No

Unsure

27

Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something?* This field is required.For example, a reaction for which you were treated with Epinephrine or EpiPen, or for which you had to go to the hospital? People with a severe allergy to any component of the vaccine (gentamicin, ciprofloxacin, egg protein, etc.) should not receive this vaccine.

Yes

No

Unsure

28

Was the severe reaction after receiving another vaccine or another injectable medication?* This field is required.

Yes

No

Unsure

29

Have you received another vaccine or TB skin testing in the last 28 days?* This field is required.

Yes

No

Unsure

30

Which vaccine was administered?* This field is required.

31

Are you pregnant or breastfeeding?* This field is required.

Yes

No

Unknown

32

Is there a chance you could become pregnant during the next month?* This field is required.

Yes

No

Unknown

33

Have you had a seizure or other neurological problem?* This field is required.

Yes

No

Unknown

34

In the last year, have you received a transfusion of blood or blood products, or been given a medicine called immune globulin or an antiviral drug?* This field is required.

Yes

No

Unknown

35

Do you, or any person living with you or under your care, take cortisone, prednisone, other steroids, anti-cancer drugs, or x-ray treatments, or have cancer, leukemia, HIV (CD4 count below 200), or any immune system problems?* This field is required.

Yes

No

Unknown

36

Do you have a health problem with asthma or wheezing, lung, heart, kidney, or metabolic disease (diabetes), anemia, or a blood disorder?* This field is required.

Yes

No

Unknown

37

You must bring a parent or guardian

Since you have indicated you are under age 18, you must bring a parent or guardian to your Mpox vaccine appointments. Your parent or guardian must review the following Vaccine Information Statement and provide their signature.

38

Consult with your healthcare provider

Since you have indicated you have experienced an anaphylactic reaction after receiving another vaccine or injectable medication, you can not get your Mpox vaccine at Springfield-Greene County Health. Please consult your healthcare provider.

39

Vaccine Information Statement* This field is required.

40

Signature of patient or legal representative* This field is required.

Clear