COVID-19 Resource Center Use the form below to schedule an appointment for your COVID-19 vaccination. Please only schedule an appointment if you are in the current (or previous) phase. 1Vaccine Selection2Appointment Date3Patient Information Please bring your insurance or Medicare card with you. Shots will be given in the upper arm, so please wear vaccine-accessible clothing. If this is your second dose, please bring your immunization record card that you received with the first dose.Services Moderna First Dose Moderna Second Dose Services Moderna First Dose Moderna Second Dose Janssen Vaccine Where did you receive your first shot? When did you receive this shot? MM slash DD slash YYYY HiddenCurrent Date MM slash DD slash YYYY HiddenDate Difference You can only schedule for your Second Moderna Dose 28 days after your first dose.COVID-19 Vaccine* June 2022 Mon Tue Wed Thu Fri Sat Sun 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 June 28, 2022 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM June 29, 2022 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM June 30, 2022 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM Name* First Last Phone*You will receive a text message reminder before your appointmentEmail* ELIGIBILITY CHECKWhich of the following populations are you in?*Select18 years old or olderCOVID-19 IMMUNIZATION CONSENT FORM2117 Boston Ave. Bridgeport, CT 06610 Complete the following questions for the individual receiving the vaccine. If you answer "YES" you may not be able to receive the COVID-19 vaccine.Person receiving vaccine (legal first name, middle initial, and last name):* Street address:* City, state, and zip code* Date of birth: (please use MM/DD/YYYY format)* MM slash DD slash YYYY Ethnicity:*SelectWhiteHispanic/LatinoBlack/African AmericanNative American/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderOtherHave you had a previous COVID-19 vaccine?* Yes No If yes, what date was the first vaccination given on? (Please use MM/DD/YYYY format) MM slash DD slash YYYY If yes, which vaccine product did you receive? Pfizer Moderna Janssen (Johnson & Johnson) Another product Name of the product Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?* Yes No Have you had any vaccines within the previous 14 days? Pfizer BioNTech or Moderna COVID-19 vaccine should be administered alone with minimal interval of 14 days before or after any other vaccine.* Yes No Do you have a fever today? Are you sick today? Do you have COVID-19 infection and are currently in isolation? Are you currently in quarantine for known exposure of COVID-19?* Yes No Have you ever had an 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.)Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures.* Yes No Polysorbate, which is found in some vaccines, film coated tablets, and intravenous steroids.* Yes No A previous dose of COVID-19 vaccine.* Yes No A vaccine or injectable therapy that contains multiple components, one of which is a COVID-19 vaccine component, but it is not known which component elicited the immediate reaction.* Yes No 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 [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.) Yes No Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, or any vaccine or injectable medication? This would include food, pet, venom, environmental, or oral medication allergies.* Yes No Are you pregnant, breastfeeding, or planning to become pregnant? Women in this group may receive Pfizer-BioNTech or Moderna COVID-19 vaccine, a discussion with your healthcare provider can help make an informed decision.* Yes No Are you immunocompromised or have HIV, cancer, chronic kidney, lung, heart disease, sickle cell, severe obesity, diabetes, or smoke? Are you receiving immunosuppressive therapy? You may still receive the vaccine unless otherwise contraindicated.* Yes No Have you received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment? Pfizer-BioNTech or Moderna COVID-19 vaccine should be deferred for at least 90 days to avoid interference of treatment with vaccine-induced immune responses.* Yes No Do you have a bleeding disorder or are you taking a blood thinner?* Yes No Are you pregnant or breastfeeding?* Yes No OPTIONAL: Upload an image or PDF of your insurance coverage information here.OPTIONAL: Upload an image or PDF of your insurance coverage information here.Max. file size: 400 MB.RELEASE & ASSIGNMENTBy scheduling this appointment, I attest that all information provided herein is accurate to my knowledge and abides by Connecticut State Department of Health guidelines regarding the status of my eligibility group. This attestation shall also serve as an electronic signature in lieu of a physical signature on this form, indicating I understand and agree to Release and Assignment of the COVID-19 Immunization Consent Form and Vaccine Recipient Emergency Use of Authorization Fact Sheet (EUA). This form is available at the pharmacy by request.* I have read and agree to the terms above** By checking the box, I indicate that I have read, understand, and agree, to "Section 2: release and assignment of the COVID-19 Immunization Consent Form and Vaccine Recipient Emergency Use of Authorization Fact Sheet (EUA).* Covid-19 Resources Connecticut COVID-19 Response
