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.**
Select which vaccine(s) you would like to receive at the clinic:

FluModerna COVID-19 (mNEXSPIKE)Shingrix (shingles)Prevnar 20 (pneumonia)RSVTdap (Tetanus)
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*
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
Are you sick today?*

YesNo
In the past two weeks have you tested positive for Covid-19 or are you currently being monitored for COVID-19?*

YesNo
**Please wait until your COVID-19 infection or observation is completed prior to receiving any vaccines**
Do you have allergies to medications, food, or vaccine?*

YesNo
If yes, what allergies do you have?
Do you have a history of Guillain-Barre Syndrome?*

YesNo
Have you ever had a serious reaction (e.g. anaphylaxis) after receiving an immunization?*

YesNo
If yes, what happened?*
Are you currently being treated for a long-term health problem such as heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia or other blood disorder?*

YesNo
Are you currently being treated for cancer, leukemia, AIDS, or any other immune system problem?*

YesNo
Are you currently taking cortisone, prednisone, other steroids or anti-cancer drugs, or have you had X-ray treatments?*

YesNo
Have you ever fainted or felt dizzy after receiving an immunization?*

YesNo
Have you had a seizure, brain, or nerve problem?*

YesNo
During the past year, have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin?*

YesNo
Have you received any vaccinations in the past 4 weeks?*

YesNo
Are you allergic to eggs?*

YesNo
Are you allergic to latex?*

YesNo
Are you pregnant or is there a change you could become pregnant during the next month?*

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