English
MyChart
teenhealthcare.org
DOH/DOE
How old are you (the person filling out this form)?
under 13 years old
13 years or older
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
No
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
* must provide value
first name
Last Name of person to be vaccinated
* must provide value
last name
Date of Birth of person to be vaccinated
* must provide value
M-D-Y
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Are you the parent or legal guardian of the person to be vaccinated?
* must provide value
Yes
No
parent/guardian name
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.
* must provide value
Please read the statement and check the box below.
* must provide value
Person getting vaccinated must be 12 or older to receive the COVID-19 vaccine at this time. Gender of person to be vaccinated
* must provide value
Male
Female
Trans Male
Trans Female
Nonbinary
Something else:
Preferred language of person to be vaccinated
* must provide value
English
Spanish
Other:
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:
Street address of person to be vaccinated
* must provide value
State
* must provide value
Zip code
* must provide value
Email of person to be vaccinated
* must provide value
Preferred method of communication
* must provide value
Email for confirmation of appointment
* must provide value
Phone number?
* must provide value
Please indicate who this number belongs to.
Person being vaccinated
Parent/Guardian
Other relative
Friend
Significant other/partner
Someone else
Is it ok to leave a message?
* must provide value
Yes
No
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
No
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
Today 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
No
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
Today 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
No
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
Today M-D-Y
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Vaccine Location:
Mount Sinai Hospital (MSH) Ross Park Tent1190 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 Tent1190 5th Avenue, New York, NY
Select all of the times you are available for a COVID-19 vaccine appointment?
*must provide value
-Select location above to view times-
Select all of the times you are available for a COVID-19 vaccine appointment?
*must provide value
Select all of the times you are available for a COVID-19 vaccine appointment?
*must provide value
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
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.