Fall 2024 COVID-19 & Flu Vaccine Sign Up

The CDC recommends that all patients aged 6 months and older receive the new 2024-2025 COVID-19 vaccine. 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. Thank you.

Please note:

Everyone ages 6 months and older should receive a 2024-2025 COVID-19 vaccine. This includes people who have received a COVID-19 vaccine in the past, and people who have previously had COVID-19.
- People who recently had COVID-19 may consider delaying their vaccine for 3 months. Please speak with your PCP if you have had COVID-19 in the past 90 days.
It is safe to receive the COVID-19 vaccine & 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 ages 3 years and up. Please contact your pediatrician for vaccination if your child is less than 3 years old.

Patient's full name*

First NameLast Name

Name of accompanying adult if patient under 16/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.

Have you received a covid-19 vaccine in the last 2 months?*

NoYes -- please return when 2 months have passed since your last covid-19 vaccine.

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 vaccine.

Are you (or the patient receiving the vaccine) at least 3 years old?*

Yes, I am at least 3 years old and would like a COVID and/or flu vaccine.No, I am a child under 3 years old-- Unfortunately, you are not eligible to receive a COVID or flu vaccine at a pharmacy. Please contact your pediatrician (we are only permitted to administer vaccinations in patients ages 3+).

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

Pfizer '24-'25 (Comirnaty) COVID-19 VaccineModerna '24-'25 (Spikevax) Covid-19 VaccineInfluenza (flu) vaccine (ages 3-64)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 vaccine (ages 50+) 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.Not today.

Signature of patient/guardian who completed application*

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

Influenza VIS: Vaccine Information - The Vaccine Information Statement (VIS) contains helpful information about the above FDA-approved vaccines. 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. If you have questions, the pharmacist will be glad to discuss them with you.

COVID-19 VIS: Vaccine Information - The Vaccine Information Statement (VIS) contains helpful information about the above FDA-approved vaccines. If you have questions, the pharmacist will be glad to discuss them with you.

Fall 2024 COVID-19 & Flu Vaccine Sign Up

Basic Demographic Information

Immunization Screening Questionnaire