Updated Covid 2023-2024 Booster and/or Flu sign-up

As of 9/12/23, the CDC recommends that all patients aged 6 months and older receive the new COVID booster that targets currently circulating variants. Please use the form below to sign up for a vaccine with us here at MLP.

*Please anticipate a wait as we check you in and check in patients ahead of you. This is not an appointment, just a way of filling out the screening questionnaire in advance to save you some time at the store. Thank you :)

Please note:

All patients 6 months and up are eligible to receive the updated mRNA COVID-19 vaccine if it has been at least 2 months since the last dose of any COVID-19 vaccine.
It is safe to receive the covid-19 booster & flu vaccine in the same visit. Please use the form below to sign up for a covid-19 booster, a flu vaccine, or both.
We are currently only permitted to administer vaccines to patients aged 3 years and up. Please contact your pediatrician if your child is less than 3 years old.

*

Patient's full name*

First NameLast Name

Name of accompanying adult if patient under 18/minor

First NameLast Name

Date of birth:*

Gender (assigned at birth):*

The CDC requires us to collect this demographic information for COVID-19 vaccinations.

Last 4 digits of SSN*

4 digits

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 will allow us to send you an appointment confirmation.

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

Date

Have you received a COVID-19 immunization dose in the last two months?*

NoYes - you are not currently eligible for the updated booster. Please return at a later date.

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

NoYes - please delay vaccination.

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

NoYes- please return when you are fully recovered. You may want to consider speaking with your PCP/doctor about waiting for 90 days before receiving this updated booster.

If you are receiving the covid-19 vaccine, are you at least 12 years old?*

Yes, I am at least 12 years old and would like to receive the adult covid-19 vaccine.No, I am under 12 and would like a pediatric covid-19 vaccine (please call the pharmacy at 401-619-5020 to discuss pediatric covid vaccine availability)Not applicable, I would only like a flu vaccine.

If you are receiving the flu vaccine, are you at least 3 years old?*

Yes, I am at least 3 years old and would like a flu vaccine.No, I am under 3 years old. Unfortunately, you are not eligible to receive a flu vaccine at Matt's Local Pharmacy. Please contact your pediatrician (we are only permitted to administer flu shots in patients ages 3+).Not applicable, I would only like a covid-19 vaccine

Which vaccine(s) will you be receiving with us during your visit?*

Pfizer (Comirnaty) covid vaccine '23-'24 updated doseInfluenza (flu) vaccine regular-dose (ages 3+)Influenza (flu) vaccine high-dose (for ages 65+)

Do you have a history of allergic reactions or allergies to latex, medications, food or vaccines(Examples: polyethylene glycol, polysorbate, eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast, and thimerosal)?) (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 notify pharmacy staff at desk 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).

Have you ever had a serious reaction after receiving a vaccination? Do you have a history of fainting, particularly with vaccines? Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*

NoYes - please notify pharmacy staff at desk during check-in.

Have you had a seizure or a brain or other nervous system problem or Guillain-Barré Syndrome?*

NoYes - please discuss your vaccine eligibility with your PCP/doctor prior to receiving a vaccine with us. After discussing with your medical professional, please notify pharmacy staff at desk during check-in.

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

NoYes - please inform your immunizer prior to vaccination.

*Have you been treated with antibody therapy (monoclonal antibodies or convalescent plasma) specifically for COVID-19?*

NoYes - We recommend checking with your healthcare provider to confirm your eligibility to receive the COVID-19 vaccination at this time.

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 to confirm your eligibility to receive the covid-19 vaccination 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 i.e. Humira®, Remicade®, etc.)?*

NoYes - We recommend checking with your healthcare provider to confirm your eligibility to receive the COVID-19 vaccination at this time. Please review timing of your immunosuppressive therapy with your provider before receiving your booster.

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

NoYes - We recommend checking with your healthcare provider to confirm your eligibility to receive the COVID-19 vaccination at this time.

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 - We recommend checking with your healthcare provider to confirm your eligibility to receive the COVID-19 vaccination at this time.

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.

Are you interested in receiving a shingles (ages 50+), RSV (ages 60+), or pneumonia vaccine during your visit with us? It is safe to receive multiple vaccines in the same visit.*

Yes - let us know at check-in that you would like to add on a shingles vaccine, pneumonia vaccine, or RSV vaccine.Not today.

Signature of patient/guardian who completed application*

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

Influenza VIS: Vaccine Information - The Vaccine Information Statement (VIS) contains helpful information about the above FDA-approved vaccines. The Emergency Use Authorization (EUA) fact sheet covers known and potential benefits and risks of the vaccine expedited for use without full FDA approval. If you have questions, the pharmacist will be glad to discuss them with you.

Comirnaty (Pfizer) EUA: Vaccine Information - The Vaccine Information Statement (VIS) contains helpful information about the above FDA-approved vaccines. The Emergency Use Authorization (EUA) fact sheet covers known and potential benefits and risks of the vaccine expedited for use without full FDA approval. If you have questions, the pharmacist will be glad to discuss them with you.

Spikevax (Moderna) EUA: Vaccine Information - The Vaccine Information Statement (VIS) contains helpful information about the above FDA-approved vaccines. The Emergency Use Authorization (EUA) fact sheet covers known and potential benefits and risks of the vaccine expedited for use without full FDA approval. If you have questions, the pharmacist will be glad to discuss them with you.

Abrysvo (RSV) VIS: The Vaccine Information Statement (VIS) contains helpful information about the above FDA-approved vaccines. The Emergency Use Authorization (EUA) fact sheet covers known and potential benefits and risks of the vaccine expedited for use without full FDA approval. If you have questions, the pharmacist will be glad to discuss them with you.

Shingrix (Shingles) VIS: Vaccine Information - The Vaccine Information Statement (VIS) contains helpful information about the above FDA-approved vaccines. The Emergency Use Authorization (EUA) fact sheet covers known and potential benefits and risks of the vaccine expedited for use without full FDA approval. If you have questions, the pharmacist will be glad to discuss them with you.

Updated Covid 2023-2024 Booster and/or Flu sign-up

Basic Demographic Information

Immunization Screening Questionnaire