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MCDH Pfizer Vaccine online form (5-11 years old)

1. Contact Information

First Name

Last Name

Address - Physical

Apt/Suite

City

State

Zip

County

Email Address This question requires a valid email address.

Phone Number - Mobile

Phone Number - Home

2. Communication Preference

3. Date of Birth This question requires a valid date format of MM/DD/YYYY.

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4. Age This question requires a valid number format.

5. Race

6. Gender

7. Ethnicity

8. Preferred Language

Please enter an 'other' value for this selection.

9. Insurance Coverage

Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.

10. Please attach a copy of your insurance card.

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11. Employer's Name/Organization/Facility you reside in

12. Are you an essential frontline worker? (Police, Food Processing, Teacher, etc.)

13. Do you reside or work in a long-term care/assisted living facility?

14. Are you feeling sick today?

15. Have you ever received a dose of COVID-19 vaccine?

Which vaccine product have you received?

What was the date of your first dose? This question requires a valid date format of MM/DD/YYYY.

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Have you ever received a second dose of COVID-19 vaccine?

What was the date of your second dose? This question requires a valid date format of MM/DD/YYYY.

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16. Have you had a severe allergic reaction to:
(This would include a severe allergic reaction (e.g. anaphylaxis) that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)

Space Cell	Yes	No
A component of COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures.	A component of COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures.: Yes	A component of COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures.: No
Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids.	Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids.: Yes	Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids.: No
A previous dose of COVID-19 vaccine.	A previous dose of COVID-19 vaccine. : Yes	A previous dose of COVID-19 vaccine. : No

17. Have you ever had an allergic reaction to another vaccine (other than COVID-19) vaccine) or an injectable medication (This would include a severe allergic reaction as stated above).