Request for COVID Vaccine

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o5aNXzirzgs4EtjN6IQ9hz9b8ydDjuPsfErUa8CAQFBkR32kAea434LcUGAaggwWoU7UpHorpDVcSitVjNGUatYNu3iu385LAixZgH2r2

By completing this form, you certify that you are at least 12 years of age and live, work or study in New York State.

If you are under 18, you must have consent from your parent or legal guardian. This consent can be in-person, written, or by phone at the time of the appointment.

The COVID-19 vaccine is free of charge for everyone, whether or not you have insurance. Although your insurance information is requested, please be assured that you will NOT be charged for the vaccine.

English

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Source

MyChart

teenhealthcare.org

DOH/DOE

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How old are you (the person filling out this form)?

under 13 years old

13 years or older

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Looks like you’re too young to complete this form online. Please have your parent/guardian complete it instead.

Has the person getting vaccinated already received a dose of the COVID-19 vaccine?

* must provide value

Yes

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If person getting vaccinated already received a first dose of COVID-19 vaccine, the second dose MUST be the same type of vaccine at the same location. This request is only for scheduling of Dose 1 of the Pfizer COVID-19 Vaccine.

First Name of person to be vaccinated

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Last Name of person to be vaccinated

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Date of Birth of person to be vaccinated

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M-D-Y

Age

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Are you the parent or legal guardian of the person to be vaccinated?

* must provide value

Yes

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Enter your full name in the box and then add your signature below.

I, , give consent for to get the COVID-19 Vaccine by Pfizer.

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Add signature

Please read the statement and check the box below.

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I understand that Parental/Guardian consent is required for the COVID vaccine. Verbal consent by my parent/guardian will be obtained by phone if I come to my appointment unaccompanied.

Person getting vaccinated must be 12 or older to receive the COVID-19 vaccine at this time.

Gender of person to be vaccinated

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Male

Female

Trans Male

Trans Female

Nonbinary

Something else:

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Preferred language of person to be vaccinated

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English

Spanish

Other:

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A mailing address is required to register for an appointment.

Address of the person to be vaccinated:

Street address:
Apartment, suite, etc.:
City:
State:
Zipcode:

Email of person to be vaccinated

* must provide value

Preferred method of communication

* must provide value

Phone call

Email for confirmation of appointment

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Phone number?

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Please indicate who this number belongs to.

Person being vaccinated

Parent/Guardian

Other relative

Friend

Significant other/partner

Someone else

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Is it ok to leave a message?

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Yes

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Has the person getting vaccinated had any vaccines in the past 14 days (2 weeks) including flu shot? This includes Meningitis, Hepatitis, HPV or any other vaccine.

* must provide value

Yes

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What was the date of the vaccine you received in the last 14 days (2 weeks)?
The COVID-19 Dose 1 appointment will be scheduled at least 14 days from your last shot.

* must provide value

M-D-Y

In the last 10 days, has the person getting vaccinated had a COVID-19 test because they had symptoms and are still awaiting the test results or been told by a health care provider or health department to isolate or quarantine at home due to COVID-19 infection, exposure or travel?

* must provide value

Yes

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What was the date of the COVID test you received or date of exposure in the last 10 days?
The COVID-19 Dose 1 appointment will be scheduled at least 14 days from your COVID test or date of exposure.

* must provide value

M-D-Y

Has the person being vaccinated been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)?

* must provide value

Yes

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What was the date the person being vaccinated was treated with antibody therapy or convalescent plasma for COVID 19?
The COVID-19 Dose 1 appointment will be scheduled at least 90 days since your treatment.

* must provide value

M-D-Y

daysout

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Vaccine Location:

Mount Sinai Hospital (MSH) Ross Park Tent
1190 5th Avenue New York, NY

At which location do you want to get your COVID Vaccine?

* must provide value

Mount Sinai Adolescent Health Center (MSAHC)
312 East 94th Street, New York, NY

Mount Sinai Hospital (MSH) Ross Park Tent
1190 5th Avenue, New York, NY

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Select all of the times you are available for a COVID-19 vaccine appointment?

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-Select location above to view times-

Select all of the times you are available for a COVID-19 vaccine appointment?

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Mondays

Select all of the times you are available for a COVID-19 vaccine appointment?

*must provide value

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Wednesdays

9:00 am - 10:00 am

10:00 am - 11:00 am

11:00 am - 12:00 pm

1:00 pm - 2:00 pm

2:00 pm - 3:00 pm

3:00 pm - 4:00 pm

You will receive a phone call or email confirming the exact day and time of the appointment within 1 business day of submitting this form.

Please complete this online form as required by NYS. When person getting vaccinated arrives for their appointment, they will be asked for proof of completion of this form: https://forms.ny.gov/s3/vaccine

All persons are screened for possible exposure to COVID at entry and will be asked the following questions before being allowed into the facility.

In the past 2 weeks, have you been told by public health authorities or a healthcare professional to self-quarantine or isolate?

Are you currently experiencing any of the following symptoms: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?

In the past 2 weeks, have you been in contact with somone with known or suspected coronavirus (COVID-19)?

The Mount Sinai Adolescent Health Center provides free, comprehensive, confidential health care to young people ages 10-26. No immigration restrictions, no insurance needed. Our services include primary, mental health, sexual and reproductive health, prenatal, dental and optical care. We also provide specialized services for LGBTQ and transgender youth, young parents, young people living with HIV, and survivors/victims of violence. We are located at 312 E. 94th Street, New York, NY 10128. For more information about us, please visit www.teenhealthcare.org.

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Looks like you’re too young to complete this form online. Please have your parent/guardian complete it instead.

I, , give consent for ______ ______ to get the COVID-19 Vaccine by Pfizer.

Person getting vaccinated must be 12 or older to receive the COVID-19 vaccine at this time.

You have selected an option that triggers this survey to end right now.

I, , give consent for to get the COVID-19 Vaccine by Pfizer.