Vaccine Application Questions
Email *
First Name *
Last Name *
Street Address *
Zip Code (Note that the City and State is automatically filled by the appointment website) *
Birthdate *
MM
/
DD
/
YYYY
Cell Number *
Email Address *
Gender (optional) *
When would you like the appointment? You can give the date and time. NYS now allows you to walk in, so the appointments are easy to book
First Site Preference *
Second Site Preference (optional and will only be used if appointments at the first site are unavailable or difficult) NOTE: Presently I have been only using first site preferences
The signup page allows for Primary Care Provider Information to be provided. To expedite the signup process, this question will be skipped. If this is important to you, please email me before signing up or make sure you provide this information when you arrive for your appointment. Click below to confirm you understand the foregoing.
The signup page allows for Emergency Contact Information to be provided. To expedite the signup process, this question will be skipped (except in the case of minors where the phone number listed above will be used). if this is important to you, please email me before signing up or make sure you provide this information when you arrive for your appointment. Click below to confirm you understand the foregoing.
Race
Ethnicity
What method of transportation will you use to get to the site
Do you require handicap access to the building?
Will you you need a translator?
Do you have Insurance? If you do not have insurance you can still receive the vaccine. If you click Yes then you must supply insurance information to be able to make the appointment.
Clear selection
If you have COMMERCIAL INSURANCE then provide: 1) Insurance Name 2) Insurance ID 3) Insurance Group (if available) 4) Insurance State
If you have MEDICAID then provide: 1) Insurance Name 2) Medicaid CIN 3) Medicaid ID (if different than Medicaid CIN) 4) Insurance Company State
If you have MEDICARE then provide: 1) Insurance Name 2) Insurance ID 3) Insurance Group ID (if available) 4) Insurance State
For ALL INSURANCE provide Primary Subscriber information: 1) First Name 2) Last Name 3) date of Birth and 4) Relationship to Patient
By clicking "yes" you confirm that I can click the link on their website that confirms that you have read the Notice of Privacy Practice (see link in Q&A at end) and that you will also receive a copy via email
Clear selection
Under the age of 12
For minors 18 and under, provide: Parent's first name, last name and maiden name AND parent's date of birth. A parent must attend the appointment
Are you feeling sick today
In the last 10 days, have you had a positive COVID-19 test or been told by a healthcare provider or health department to isolate or quarantine at home IF YES YOU ARE INELIGIBLE
Have you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)?
Have you ever had an immediate allergic reaction, such as hives, facial swelling, or difficulty breathing or anaphylaxis, to any vaccine or shot or to any component of the COVID-19 vaccine, such as PEG or polysorbate?
Have you had any vaccines in the past 14 days (2 weeks) including flu shot? IF YES YOU ARE INELIGIBLE
Are you pregnant or considering becoming pregnant?
Do you have a bleeding disorder or are you currently taking a blood thinner?
Do you have cancer, leukemia, HIV/AIDS, a history of autoimmune disease or any other condition that weakens the immune system?
Do you take any medications that affect your immune system, such as cortisone, prednisone or other steroids, anticancer drugs, or have you had any radiation treatments?
Have you ever received a dose of the COVID-19 vaccine?
Please provide your qualification for being eligible and if there is any information you wish to provide you, you can write it here. You can also email me at Sam@VaccineHelper.com
You must confirm that you’re eligible and bring ID and proof of qualification to the appointment. By submitting, you are authorizing VaccineHelper to obtain a vaccine appointment on your behalf and you agree that VaccineHelper.com and its principals and agents have no liability of any nature for any assistance they provide.
A copy of your responses will be emailed to the address you provided.
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