COVID-19 Vaccine Reservation

Please fill out your personal information and answer the following questions before confirming your reservation:

Are you completing this for yourself or a minor?*

What is your relation to the minor?

Full name of person completing this form (if you are accompanying this minor, please bring a government issued ID on site to confirm identity

Minor's approximate weight in pounds

Patient legal first name*

Patient legal last name*

Date of birth*

Gender*

Race*

Ethnicity*

Address*

City*

State*

Zip code*

County (KY only)

Email*

Phone Number (if this appointment is for a minor, please put parent/guardian's phone number)*

Sign up for text message reminders? You will receive automated reminder messages for your upcoming vaccination and second/third dose scheduling if applicable. Msg & data rates may apply.*

Household income*

Select one of the following*

If this is your second/third dose, please specify which vaccine you previously received

Are you an immunocompromised individual?*

Please mark what applies to you (Note, you do not need insurance to receive the vaccine)*

Are you pregnant? (if yes, please speak to your OB/GYN doctor prior to your visit)*

Have you tested positive for COVID-19 in the last 14 days?*

Have you had a live vaccine within the past two weeks? (examples MMR, Polio, Nasal influenza)*

Have you had any reactions to vaccines in the past such as feeling lightheaded, woozy/nauseous, passing out, or anaphylaxis? (if yes, you may be asked to wait an additional 15 minutes post vaccine)*

Do you have any allergies towards shellfish/bee stings? (if yes, you may be asked to wait an additional 15 minutes post vaccine)*

Do you have an allergy to polyethylene glycol (PEG)? This is the primary ingredient in Miralax and may be found in other medications. (if yes, you may not receive the Pfizer-BioNTech Covid-19 vaccine)*

Do you have any seasonal allergies, dry skin, or asthma? (if yes, you may be asked to wait an additional 15 minutes post vaccine)*

Other allergies

Have you received monoclonal antibody treatment for Covid-19 infection in the past 90 days? (This treatment is given via an IV infusion in the hospital. if yes, you may not receive this vaccine until it is has been more than 90 days)*

If you have any questions, please contact the Wildhealth Help Desk: (859) 217-4679