BR 2024 Clinic Sign-In & Questionnaire

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Date
Date
Month
Day
Year
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Hour
18
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Minutes
PM
AM
PM
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Have you preregistered for this clinic?Did you already fill out the full pre-vaccination questionnaire?
YESNO
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Which clinic do you plan on attending
Please Select
Please Select
Thursday, 5/15/25 @ Oak Street Health (10AM - 2PM)
Friday, 5/16/25 @ Arsenal K-8 "Take a Father to School" Day
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The regristration for the clinic you are signing up for is closed - please proceed to the clinic and ask for a paper registration. Thank you.
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Date 1
Date
Month
Day
Year
6
Patient Name* This field is required.
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Clinic
8
Date of Birth* This field is required.
Date
Month
Day
Year
9
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Phone Number
Area Code
Phone Number
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May we call or text you at this numberWe will only contact you with a reminder about the clinic, and/or to clarify insurance information.
May Call
May Text
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Social Security Number* This field is required.
For insurance purposes
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Race
Asian
Black
Hispanic/Latino
White
Prefer not to answer
Other
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Gender
Male
Female
15
Zip Code
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Vaccine* This field is required.Please select the vaccine you are interested in receiving.
COVID-19
Pneumonia
Flu
Shingles
RSV
Tetanus
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Do you have health insurance?
Yes
No
18
Please see the event coordinator or pharmacist for more information.
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Please take a picture of your Insurance card:
20
Age (days)
21
Age
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You do not meet the age requirement for this vaccine.

RSV: Over 75 years old

Shingles: Over 50 years old

COVID: 12+ for applicants over 12 years of age

Please uncheck the vaccine box and continue.

ONLY CLICK NEXT** IF YOU ARE CONSIDERED AT INCREASED RISK

(chronic heart or lung disease; weakened immune system, severe obesity, severe diabetes, live in a nursing home or other long-term care facility)

** Clicking next is an attestation that you fall under one of the above categories
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Please select one of the vaccine choices listed on the previous page.
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Flu
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COVID 1
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COVID 2
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Notes
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Are you feeling sick or have a moderate to high fever today?
YESNO
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Please explain
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Have you ever had a severe allergic reaction to any food, medication or vaccine, including fainting or feeling dizzy?
YESNO
31
Please explain
32
Have you had Guillain-Barre Syndrome, Seizure, brain or nerve problems?
YESNO
33
Please explain
Huge
Large
Normal
Small
Ok
Ok
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Do you have a weakened immune system caused by something such as HIV infection or cancer, or do you take immunosuppressive drugs or therapies?
YESNO
35
Please explain
Huge
Large
Normal
Small
Ok
Ok
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Do you have a bleeding disorder or are you taking a blood thinner?
YESNO
37
Please explain
Huge
Large
Normal
Small
Ok
Ok
38
Are you pregnant or breastfeeding?
YESNO
39
Please sign here to attest the information on this form to be correct.
Clear
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I have read or had explained to me the current Vaccine Information Statement (VIS) or End Use Authorization (EUA) for this vaccine and understand the risks and benefits. CONSENT -- By signing below, I give consent to Livingston Pharmacy and its staff, to vaccinate myself with the requested vaccine, and to report any data collected on this form to the required State and/or Federal agencies as required (if this consent form is not signed, then the patient will not be vaccinated). I also verify that I have been offered the Vaccination Information Fact Sheet on the date this form was signed. I further consent to remain near the vaccination area for approximately 15 minutes following vaccination for observation by the pharmacist. I also agree to hold harmless Livingston Pharmacy, its directors, officers, employees, agents, and stockholders from and against all claims, demands, actions, suits, damages, liabilities, losses, settlements, judgments, costs and expenses (including but not limited to reasonable attorney fees and costs), whether or not involving a third-party claim, which may arise out of, or related to, the administration of this vaccine.
Clear
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