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Montgomery County PA
Registration
First Dose
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Have you received any dose of a COVID-19 vaccine?
Have you received any dose of a COVID-19 vaccine?
No
Have you received any dose of a COVID-19 vaccine?
Yes
What was the date that you received the dose?
*
What was the vaccine type?
Moderna (Age 6mo-5yr) Bivalant
Moderna (Age 12+) Bivalent
SERIES - Pfizer-BioNTech (Age 6mo-4yr) Bivalent
Pfizer-BioNTech (Age 5-11) Bivalent
Pfizer-BioNTech (Age 12+) Bivalent
If you received the first of a two-part vaccine somewhere else, we need you to answer some registration questions before scheduling the second dose with us. Click “Next” to get started.
What Other COVID-19 Vaccine brand did you receive?
AstraZeneca-Oxford (Covishield, Vaxzevria)
Bharat Biotech International
Novavax
Other/Don't remember
Sinopharm
Sinovac
What COVID-19 vaccine brand do you want to receive for this COVID-19 registration?
(Please do not select Other.)
We will do everything we can to accommodate your selection; however, we comply with CDC guidelines.
Moderna (Age 6mo-5yr) Bivalant
Moderna (Age 12+) Bivalent
SERIES - Pfizer-BioNTech (Age 6mo-4yr) Bivalent
Pfizer-BioNTech (Age 5-11) Bivalent
Pfizer-BioNTech (Age 12+) Bivalent
Medical History
Have you had a severe allergic reaction to ANYTHING - including food, medication, previous vaccines or anything else?
Have you had a severe allergic reaction to ANYTHING - including food, medication, previous vaccines or anything else?
No
Have you had a severe allergic reaction to ANYTHING - including food, medication, previous vaccines or anything else?
Yes
Have you ever had a serious reaction after receiving a vaccination?
Have you ever had a serious reaction after receiving a vaccination?
No
Have you ever had a serious reaction after receiving a vaccination?
Yes
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have a bleeding disorder or are you taking a blood thinner?
No
Do you have a bleeding disorder or are you taking a blood thinner?
Yes
Has the person to be vaccinated ever had Guillain-Barré syndrome?
Has the person to be vaccinated ever had Guillain-Barré syndrome?
No
Has the person to be vaccinated ever had Guillain-Barré syndrome?
Yes
Have you ever received treatment for COVID-19?
Have you ever received treatment for COVID-19?
No
Have you ever received treatment for COVID-19?
Yes
Vaccination Type
*
Covid-19 Series Vaccination
Covid-19 Booster Vaccination
General Vaccination
