2025-09-29 - Flu and COVID-19 Vaccine Appointment Request and Consent Form

Vaccine Appointment Request and Consent Form
Pediatric Associates is excited to offer online appointment requests for Flu vaccinations!

If your child is not a current patient we will not be able to schedule an appointment through this form. Please CLICK HERE to request to become a patient!

If you do not see an available appointment at your preferred office or preferred date please call 912-355-2462 as we may still have slots available.

Please complete the form and we will contact you to confirm your request no later than 48 hours prior to your appointment.

We will be offering WEEKEND VACCINE CLINICS on limited dates at our MAIN office on Waters Avenue! Please select "MAIN OFFICE" then "WEEKEND CLINIC" to see if there are any available appointments.
Please select an office:
Vaccine(s) Requested (select all that apply):

Main Office

4600 Waters Ave., Suite 100, Savannah, GA 31404
Waters Office Weekend Clinic - Select a date and time
Waters Weekday Clinic - Select a date and time
Pooler Office

110 Medical Park Drive, Pooler, GA 31322
Pooler Weekday Clinic - Select a date and time
Pooler Weekend Clinic - Select a date and time
Whitemarsh Island Office

1001 Memorial Dr, Savannah, GA 31410
Islands Weekday Clinic - Select a date and time
Vaccine During Existing Appointment - Select the date and time of you child's upcoming appointment:

Patient Information
Name

First NameLast Name
Sex
Date of Birth

MonthDayYear
Confirm age of recipient on the requested appointment date

Flu Vaccine Consent
"Flu Shot" - Inactivated/Recombinant Influenza Vaccine (6 months and up) information:
"Flu Mist" - Intranasal Live Influenza Vaccine (2 years and up, no history of wheezing)
I have reviewed the Vaccine Information Statements above and consent for the patient to receive the following vaccine:

COVID-19 Vaccine Consent
Moderna SPIKEVAX Information ALL AGES
COVID-19 Vaccine Information Sheet
I have reviewed both the SPIKEVAX Information for Recipients and Cargivers and Vaccine Information Statements above and consent for the patient to receive the COVID-19 vaccine:

Consent for vaccination
Signature of guardian (or recipient if over 18 years of age):
Name of guardian (or recipient if over 18 years of age):

First NameLast Name
Phone Number of guardian (or recipient if over 18 years of age):
Please enter a valid phone number.Format: (000) 000-0000.
Email of guardian (or recipient if over 18 years of age):

Confirmation Email
Appointment Request Summary
By clicking submit I agree to all of the above and I hereby give my consent to the staff of Pediatric Associates of Savannah, PC to give the recipient all vaccines requested. I understand the date and time of the appointment is not finalized and will wait for further confirmation from Pediatric Associates of Savannah, PC.
Should be Empty:

Rows	Yes	No	Not Sure
1. Is the patient sick?
2. Does the patient have allergies to medications, food, a vaccine component, eggs, or latex?
3. Has the patient had a serious reaction to a vaccine in the past?
4. Has the patient had a health problem with lung, heart, kidney or metabolic disease (e.g., diabetes), asthma, or a blood disorder? Is he/she on long-term aspirin therapy?
5. Has a health care provider told you that the patient has had wheezing or asthma in the past 12 months?
6. If the patient is a baby, have you ever been told he or she has had intussusception?
7. Has the patient, a sibling, or a parent had a seizure; has the child had brain or other nervous system problems (e.g., Guillain-Barre syndrome)?
8. Does the patient have cancer, leukemia, HIV/AIDS, or any other immune system problem?
9. In the past 1-3 months, has the patient taken medications that affect the immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatioid arthritis, Crohns's disease, or psoriasis; or had radiation treatments?
10. In the past year, has the patient received a transfusion of blood or blood products, or been given immune gamma globulin (IVIG) or an antiviral drug?
11. Is the patient pregnant or is there a chance she could become pregnant during the next month?
12. Has the patient received any vaccinations in the past 4 weeks?
13. Does the patient to be vaccinated live with or expect to have close contact with a person whose immune system is severely compromised and who must be in protective isolation (e.g., an isolation room of a bone marrow transplant unit)?
14. Has the person to be vaccinated ever had the following conditions: sickle cell disease, cochlear implant (receptient or candidate), damaged or no spleen, heart disease, kidney disease, lung disease, diabetes, alcoholism, cirrhosis, leaks of cerebrospinal fluid, or cancer?
15. Has the child ever been diagnosed with a heart condition (myocarditis or pericarditis) or have they had Multisystem Inflammatory Syndrome (MIS-C) after an infection with the virus that causes COVID-19?

Vaccine Appointment Request and Consent Form

Main Office

Pooler Office

Whitemarsh Island Office

Patient Information

Vaccine Consent Form

Flu Vaccine Consent

COVID-19 Vaccine Consent

Consent for vaccination