GP Vaccine Consent Form

Vaccine Consent Form and Scheduling
Please select a location at which to receive a vaccine:
**If the GuidePoint Pharmacy location you want to receive the vaccine from is not in drop down menu it does not use online scheduling.**
Shingrix (shingles)Prevnar 20 (pneumonia)Tdap (Tetanus)
** The Flu, COVID-19, and RSV vaccines will return in the fall. If you need it before then or have questions, please call the pharmacy where you would like to receive it. Thank you!**
All individuals 65 years and older are elgible for the COVID-19 vaccine.

Individuals under 65 years are elgible if they have a high risk condition listed below:
- Asthma
- Blood cancers
- Cerebrovascular disease
- Chronic kidney disease
- Some chronic lung diseases
- Some chronic liver diseases
- Cystic fibrosis
- Type 1 and 2 diabetes
- Gestational diabetes
- Disabilities, including Down syndrome
- Heart conditions
- HIV
- Mood disorders, including depression and schizophrenia
- Dementia
- Parkinson's disease
- Obesity
- Physical inactivity
- Current or recent pregnancy
- Primary immunodeficiencies
- Current or former smoking
- Solid organ or blood stem cell transplant recipients
- Tuberculosis
- Use of immunosuppressive drugs
Name*
Date of Birth*

MonthDayYear
Gender*
Phone Number*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mother's Maiden Name (Used for State Immunization Registry Purposes ONLY)
Schedule Appointment
Blue time slots are available.
Greyed out time slots are not available.
Brainerd*
Crosby*
Breezy Point*
Health Questionnaire
YesNo
YesNo
**Please wait until your COVID-19 infection or observation is completed prior to receiving any vaccines**
YesNo
If yes, what allergies do you have?
YesNo
YesNo
If yes, what happened?*
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Should be Empty:

Vaccine Consent Form and Scheduling

Schedule Appointment

Health Questionnaire

**Please wait until your COVID-19 infection or observation is completed prior to receiving any vaccines**

Please wait until your COVID-19 infection or observation is completed prior to receiving any vaccines