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         Fall 2026

    Roger Williams University 

    Flu/COVID-19

     

    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. Please use the form below to sign up for a COVID-19 booster, a flu vaccine, or both.

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  • Basic Demographic Information

  • Date of birth:*
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  • Immunization Screening Questionnaire

  • Have you received a covid-19 vaccine in the last 2 months?*
  • Are you feeling sick today? (If yes, please delay vaccination until symptoms are resolved)*
  • Have you tested positive for COVID-19 within the last 14 days?*
  • Which vaccine(s) will you be receiving with us during your visit?*
  • Do you have a history of allergic reactions or allergies to latex, medications, food or vaccines(Examples: polyethylene glycol, polysorbate, eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast, and thimerosal)?) (This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.)*
  • 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?*
  • Have you had a seizure or a brain or other nervous system problem or Guillain-Barré Syndrome?*
  • Do you have a bleeding disorder or take blood thinners such as Warfarin/Coumadin/ Eliquis/Xarelto?*
  • *Have you been treated with antibody therapy (monoclonal antibodies or convalescent plasma) specifically for COVID-19?*
  • 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?*
  • 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.)?*
  • Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)?*
  • Do you have a history of thrombosis with thrombocytopenia syndrome (TTS) following the Janssen COVID-19 vaccine or any other adenovirus-vectored COVID-19 vaccines (e.g., AstraZeneca's COVID-19 vaccine)?*
  • Influenza 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.
  • 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.
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