Infant RSV Interest Form (Beyfortus)

Was your child born after April 1, 2025*

YESNO

Patient Name

First NameLast Name

Which month was your child born in:

What is your child's actual Date of Birth?

Date

What is the name of the person who we should call to schedule/discuss scheduling?

First NameLast Name

What is the phone number of the contact person?

We apologize; however since your child was not born after April 1, 2025, your child is not currently eligible to receive the new RSV injection. If you have any additional questions, please ask your provider at your next well check.