Vaccine Application Questions

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Email *

First Name *

Last Name *

Street Address *

Zip Code (Note that the City and State is automatically filled by the appointment website) *

Birthdate *

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: Please tell me what areas you are willing to go. I am booking NYS, hospitals and pharmacies and will try to book a location that is close to you *

Booster, Child (age 5-112) or First Dose? If you want a booster, please provide which manufacturer made your vaccine (and confirm you want the same for your booster) and provide the date of your two shots [you must be 6 months after your second dose]. For a child, please provide parents names (only Pfizer is available). For a First Dose, please tell me which manufacturer you want *

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.

Confirmed

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.

Confirmed

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.

Yes

No By checking no, you confirm that you are uninsured. This means that you do not or will not have coverage through an individual or employer-sponsored plan, a federal healthcare program (e.g. Medicare, Medicaid), or Federal Employees Health Benefits Program at the time services will be rendered, and that no other payer will reimburse you for COVID-19 vaccination.

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

Yes

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.

Confirmed

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Vaccine Helper. Report Abuse

Forms