• Crestwood Pharmacy 26A Picotte Drive Albany, NY 12208 (518) 435 - 2315

    Please Read the following Vaccine Information Sheet (VIS)

    MNexspike ("high dose" for those 65+ or with risk for severe COVID-19) COVID-19 Vaccine Administration Form

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Please answer the following questions. They will help us determine your eligibility to receive a vaccination

  • Do you currently feel sick?*
  • Have you been sick in the last 2 weeks?*
  • Do you currently have a fever?*
  • If you are under 65 years old, do you have any health conditions listed in the list below (Please note one of these conditions is required if you are under 65)*
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  • Have you received theCOVID-19 vaccine before?*
  • Have you had a reaction to the vaccine before?*
  • Was your last COVID-19vaccine is received more than 6 months a go?*
  • Are you over 65 years old?*
  • Are you allergic to thimerosal?*
  • Are you currently pregnant? (you are not elligible to receive the vaccine if you are pregnant)*
  • Are you a healthcare worker?*
  • Have you ever had Guillain-Barre Syndrome?*
  • Do you have a blood clotting disorder?*

  • I, the undersigned, have read or had explained to me the vaccine information sheet (VIS I understand that it is not possible to predict all side effects or complications associated with receiving vaccination I understand the risks and benefits associated with the COVID-19 vaccine and have had any questions satisfactorily answered. I voluntarily request that the vaccine be given to me or for the aforementioned person for whom I am authorized to make this request.I understand that my vaccination will be submitted NYSIIS (New York State Immunization Information System) unless otherwise stated. I acknowledge that a pharmacist or certified pharmacy intern under a pharmacists supervision will be administering the vaccine.

    I acknowledge that all of the information entered above is accurate to my knowledge.

     

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Appointment*
  • Would you be interested in receiving a complimentary Narcan kit?
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  • Should be Empty: