Medway Senior Center Vaccine Clinic Monday September 15th 2025 1:30pm to 3:30 pm
Insurance Required
Patient Information
Name
*
First Name
Last Name
Gender
*
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Which vaccine would you like to receive?
*
Moderna
Pfizer
Flu (for age under 65)
Flu (for age 65 and over)
Appointment
Insurance Information
Member ID
RxBIN
RxPCN
RxGroup (RXGRP)
Screening Questionnaire
Are you sick today?
*
Yes
No
Other
Do you require an Epi-pen for emergency treatment of anaphylaxis?
*
Yes
No
Have you ever had a severe allergic reaction to a previous dose of this vaccine or to any of the ingredients of this vaccine?
*
Yes
No
Do you have allergies or reactions to any medications, foods, vaccines or latex?
*
Yes
No
If yes, please explain:
In the past 90 days, have you received monoclonal antibodies or been diagnosed with COVID-19?
*
Yes
No
In the past 10 days, have you had fever, chills, cough, shortness of breath, fatigue, headache, new loss of taste and/or smell, nausea, vomiting or diarrhea?
*
Yes
No
Are you immunocompromised or on a medicine that affects their immune system?
*
Yes
No
Do you have a bleeding disorder or are on a blood thinner?
*
Yes
No
Do you have a history of Guillain-Barré syndrome?
*
Yes
No
Other
Consent
I FULLY UNDERSTAND THAT I WILL BE ULTIMATELY RESPONSIBLE FOR ANY CHARGES if they are not a covered person under the insurance plan (program listed above), the services are not covered services, or any co-pays, deductibles or coinsurance obligations apply.
Massachusetts law (M.G.L. c. 111, Section 24M) requires providers to report immunization information to a computerized immunization registry known as the Massachusetts Immunization Information System (MIIS). The MIIS stores immunization records for your child and your healthcare provider and can help prevent outbreaks of disease like measles and the flu. All information in the MIIS is kept secure and confidential. The MIIS allows information to be shared with health care providers, school nurses, local boards of health, state agencies concerned with immunization and Health plans for immunization rate improvement and quality improvement efforts for each plan’s membership. You have the right to object to the sharing of your child's immunization information across providers in the MIIS. For more information, please ask your healthcare provider, visit the MIIS website at www.mass.gov/dph/miis or contact the Massachusetts Immunization Program MIIS Help Desk directly at 617-983-4335.
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