• Please confirm the following statements are all true:
  I have not tested positive for Covid-19 in the past 20 days
• If I have tested positive for Covid-19 or been exposed, I have not received certain injectable medication treatments for Covid-19 (Remdesivir, Monoclonal Antibodies like Bamlanivimab or Regen-Cov, Convalescent plasma) in the past 90 days.
• I have never had an allergic reaction to polyethylene glycol (PEG), polysorbate or another Covid-19 vaccine.
• I am Eligible for one of the following reasons:
  • I am scheduling to receive my primary series of covid vaccine:  Pfizer (2 doses spaced at least 21 days apart),  Moderna (2 doses spaced at least 28 days apart),  Johnson & Johnson (1 dose)
    • I require a 3^rd dose of Pfizer or Moderna 28 days following my 2^nd dose if one of the following applies:  I am undergoing active treatment for cancer (solid tumor and hematologic malignancies),  I have received a solid-organ transplant and am taking immunosuppressive therapy,  I have received a CAR-T-cell or hematopoietic stem cell transplant (within two years of transplant or taking immunosuppression therapy), I have moderate or severe primary immunodeficiency (e.g. DiGeorge syndrome, Wiskott-Aldrich syndrome), I have advanced or untreated HIV infection, I am undergoing active treatment with high-dose corticosteroid (i.e. ≥20mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor-necrosis (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory.
  • I am scheduling to receive a Booster dose of Covid vaccine and I am greater than 18 years old. I am able to choose any brand of Covid vaccine available, regardless of the brand of Covid vaccine I initially received
    • It has been at least 6 months since the completion of my Moderna primary Covid vaccination series.
    • It has been at least 5 months since the completion of my Pfizer primary Covid vaccination series.
    • It has been at least 2 months since my Johnson & Johnson COVID vaccine.
  • I am scheduling to receive a Booster dose of Covid vaccine and I am 12-17 years old.
    • It has been at least 5 months since the completion of my Pfizer primary Covid vaccination series

For more information about Covid Vaccines and Eligibility requirements, please visit the CDC website Vaccines for COVID-19 | CDC

If any of the above statements are false, please contact your Primary Care Provider before scheduling or call 419-399-1163 for further direction.

By CLICKING HERE I confirm that the above statements are true and I want to make an appointment to receive the COVID-19 vaccine.

If you need further assistance with making an appointment for a Covid vaccination, please call 419-399-1163 or e-mail us at covidvaccine@pauldingcountyhospital.com