Queens Health Systems                               Vaccination Clinic @ Bishop Museum                                                                                                                                                                                                                                             9/18 (10am-4pm)    Sat                                                                                    10/9 (10am-4pm)    Sat                                                                      10/16 (10am-4pm)  Sat                                                                                                                          
Please print and complete registration form, consent form (if under 18 years old), and pre-screening forms. Hard copies will also be available.

Registration Form:
https://bit.ly/3xOs6SW
Consent Form (if under 18, parent signature is required):
https://bit.ly/3g81Htg
COVID-19 Vaccine Pre-screening Form:
https://bit.ly/3AHhQ0s

Booster and 3rd doses attestation form:
https://bit.ly/3o6Eah2 
*Booster: 180 day minimum between 2nd dose and booster; Pfizer only.
Signature required on attestation form please.
*3rd dose: Immunocompromised individuals only, 28 day minimum between 2nd and 3rd dose.
Moderna and Pfizer only.
Signature required on attestation form please.

Fact sheets:
Pfizer: https://bit.ly/3i4WqDJ
EUA Fact sheets:
Janssen: https://bit.ly/3CObHS7
Moderna: https://bit.ly/37QsWnE

Sign in to Google to save your progress. Learn more
Date of Attendance *
Choice of Vaccine:
Clear selection
Last Name, First Name *
Address *
Age *
Date of Birth *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy