Schedule COVID-19 Vaccination Appointment Step 1 of 7 - Information 14% Date of Birth* MM slash DD slash YYYY You will need to provide a government-ID to prove your age.AgeSex* Male Female Non-Binary Prefer not to answer New York State Residency Requirement* Under penalties of perjury, I attest that I am a resident of the State of New York.VLS Pharmacy can only administer vaccines to those who live in the State of New York. If you do not reside in the State of New York, you are not eligible for a vaccine.Zip Code* ZIP Code Do you have proof of New York State residency?*Select belowYesNoThis includes: DMV issued Drivers's License / Non-Driver ID / Utility Bill / Lease or Mortgage Agreement / Bank StatementAre you a teacher/professor in a P-12 School/College an employee/staff of NYS Licensed, Registered, Approved or Legally Exempt Group Childcare Settings (including center-based and family care providers)?*Select belowYesNoDo you have one of the below comorbidities or underlying conditions?*Select belowYesNo• Cancer (current or in remission, including 9/11-related cancers); • Chronic kidney disease; • Pulmonary Disease, including but not limited to, COPD (chronic obstructive pulmonary disease), asthma (moderate-to-severe), pulmonary fibrosis, cystic fibrosis, and 9/11 related pulmonary diseases; • Intellectual and Developmental Disabilities including Down Syndrome; • Heart conditions, including but not limited to heart failure, coronary artery disease, cardiomyopathies, or hypertension (high blood pressure); • Immunocompromised state (weakened immune system) including but not limited to solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, use of other immune weakening medicines, or other causes; • Severe Obesity (BMI 40 kg/m2), Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2); • Pregnancy; • Sickle cell disease or Thalassemia; • Type 1 or 2 diabetes mellitus; • Cerebrovascular disease (affects blood vessels and blood supply to the brain); • Neurologic conditions, including but not limited to Alzheimer's Disease or dementia; and • Liver disease.At this moment, you are NOT eligible to receive the vaccine from VLS Pharmacy. Scheduling an appointment is therefore not allowed. State's eligibility requirements do change, so please check back later. Name* First Last Phone Number*Email Address* Is this your FIRST dose or SECOND dose?*Select BelowFirst (1st)Second (2nd)NY Department Of Health requires that "Those who receive the vaccine must return to the same location to receive the second dose, unless NYSDOH approves an alternative due to extenuating circumstances." If your first dose of vaccination was administered at VLS Pharmacy, the appointment for your second dose was already set-up during the time of administration. Mandatory QuestionsDid you have any acute illness with a fever of greater than 100°F within the last 24 hours?*Select an optionYESNOAre you currently in quarantine/home-isolation (e.g., post travel, post exposure) and not yet cleared for return-to-work?*Select an optionYESNOHave you been diagnosed with Covid-19 in the past 10 days?*Select an optionYESNOHave you been treated with antibody therapy for Covid-19 in the past 90 days (3 months)?*Select an optionYESNODate of Last Dose* MM slash DD slash YYYY When did you receive the last dose of Antibody Therapy for COVID-19?Have you had any vaccines in the past 14 days (2 weeks) including flu vaccine?*Select an optionYESNODate of Most Recent Vaccine* MM slash DD slash YYYY When did you receive your most recent vaccine?Have you ever had a severe/anaphylactic reaction not related to a vaccine or injectable medication?*Select an optionYESNOHave you had a severe/anaphylactic reaction to any vaccination (not including Covid vaccine) in the past?*Select an optionYESNOHave you had an allergic reaction to any injectable (e.g., intravenous, intramuscular, subcutaneous) medication in the past?*Select an optionYESNO(Note: family history of anaphylaxis is not applicable)Have you had a non-serious allergy reaction (e.g., not anaphylaxis) to any vaccinations in the past?*Select an optionYESNOAre you currently pregnant or breastfeeding?*Select an optionYESNODo you currently have any immunocompromising condition? (HIV/AIDS, cancer, leukemia, etc)*Select an optionYESNODo you have an egg allergy?*Select an optionYESNODo you have a latex allergy?*Select an optionYESNODo you have an allergy to any medication (prescription or over the counter)?*Select an optionYESNOPlease list all your allergies:*Due to one of your answers during our questionnaire, it is advised that you do NOT receive the vaccine at this time, but may be rescheduled for the future. Scheduling an appointment is therefore not allowed. Appointment Details* If there are no appointments available, an alternative option is the VLS Pharmacy Covid-19 Vaccine standby list. By joining this list, you will be contacted by VLS Pharmacy if there are more doses than people signed up to receive the vaccine. If you are interested in being placed on the standby list, you will be notified of open appointments on short notice. Click here to join the VLS Pharmacy Covid-19 standby list. Please do not call VLS Pharmacy to check on your standby status, we will contact you if an appointment opens. Being placed on the standby list does not guarantee that you will be called. Thank you. Click Here to join the COVID-19 Vaccine Standby List Consent* I agree to the following policyMy signature below indicates that I agree to receive the Covid-19 vaccine and that I also consent for the applicable Provider to report this vaccine information to the New York City Immunization Registry (CIR) or the New York State Immunization Information System (NYSIIS), as applicable for the purposes of public health reporting. Securing an appointment does not guarantee that you will receive a vaccine at your appointment, further screening is required prior to vaccine administration.Consent* I consent to the following policy about the COVID-19 VaccinationConsent I have been provided and have read, or had explained to me, the information sheet about the COVID-19 vaccination. I understand that if this vaccine requires two doses,two doses of this vaccine will need to be administered (given) in order for it to be effective. I have been given an opportunity to ask questions which were answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described. I request that the COVID-19 vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health insurance plan, Medicare, Medicaid Or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries. Recipient / Surrogate / Guardian*Please use a touch-device/mouse/cursor/finger to sign in the area. By signing, you agree to the policy set-forth above.Date - 06/15/2021Name* Please enter the name of the person who signed the consent forms.Relationship to patient, if other than recipient HiddenVaccine Manufacturer HiddenVaccine Code Descriptor HiddenVaccine Name HiddenVaccine Administration CodeDose 1 - 80777-273-10Dose 2 - 80777-0273-10HiddenEU Date HiddenPharmacist Name HiddenPharmacist SignatureHiddenInjection SiteSelect belowAdministration SiteLeftDeltoidRightDeltoidLeft ThighRight ThighHiddenInjection Route HiddenDosage HiddenLot # HiddenExpiration Date MM slash DD slash YYYY Currently, as per the New York State Department of Health, community pharmacies are only permitted to vaccinate NYS residents aged 50 and older. If you are a NYS resident under the age of 50, meet the eligibility requirements and wish to be vaccinated, you may find a mass vaccination site here. An alternative option is the VLS Pharmacy Covid-19 Vaccine standby list. By joining this list, you will be contacted by VLS Pharmacy if there are more doses than people signed up to receive the vaccine. If you are interested in being placed on the standby list, you will be notified of open appointments on short notice. Click here to join the VLS Pharmacy Covid-19 standby list. Please do not call VLS Pharmacy to check on your standby status, we will contact you if an appointment opens. Being placed on the standby list does not guarantee that you will be called. Thank you. Click Here to join the COVID-19 Vaccine Standby List At this moment, you are NOT eligible to receive the vaccine from VLS Pharmacy. Scheduling an appointment is therefore not allowed.