Fall 2025 COVID-19 Vaccine

Brown University

Please use the form below to sign up for a vaccine with us.

*Please anticipate a wait as we check you in and check in patients ahead of you. Thank you.

Please note:

The 2025-2026 COVID-19 vaccine is now available. 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.

Patient's full name*

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 (international students insert 0000)*

4 digits

Home 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 and proof of vaccination!

Upload a picture of your insurance card

Browse Files

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 90 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.

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

Pfizer '25-'26 (Comirnaty) COVID-19 VaccineModerna '25-''26 (Spikevax) Covid-19 Vaccine

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.

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.

Signature of patient/guardian who completed application*

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

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.

Have you received your Covid vaccination today??

Yes

Fall 2025 COVID-19 Vaccine

Brown University

Basic Demographic Information

Immunization Screening Questionnaire