COVID-19 Vaccine Booster Screening Form

Future Pop-Up Booster Clinics will be Announced Here

Booster Information

Pfizer: Ages 12+ at least 5 months after second dose
Moderna: Ages 18+ at least 5 months after second dose
Johnson & Johnson: 18+ at least 2 months after single dose

More booster information here.

The requested form is not available at this time.

1. Are you sick today?*
- Yes
- No
2. Have you been diagnosed with COVID-19 disease & are currently in isolation?*
- Yes
- No
3. Have you been exposed to someone with COVID- 19 disease and are currently in quarantine?*
- Yes
- No
4. Have you been treated with antibody therapy for COVID-19 in the last 90 days (3 months)?*
- Yes
- No
5. Do you have severe allergic reactions to any vaccine or shots in the past?*
- Yes
- No
6. Are you an FDA-approved age to receive the COVID-19 vaccine ?*
- Yes
- No
Name
This field is for validation purposes and should be left unchanged.

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