Immunization Scheduling and Questionnaire
What GuidePoint location would you like to receive your immunization(s)?
*
Please Select
Aitkin
Brainerd
Breezy Point
Crosby
Kemper Drug
Longville
Marshall
Nisswa
Redwood Falls
Rochester
Slayton
Check immunization(s) you wish to receive:
*
Influenza
Zoster (Shingles)
Pneumonia
Hepatitis A
Hepatitis B
Tetanus (Td,Tdap)
Other
**COVID-19 Vaccines cannot be administered with other vaccines. Any other vaccines MUST be at least 2 weeks before or after the COVID-19 vaccine.**
Name
*
Date of Birth
*
/
Month
/
Day
Year
1
Gender
*
Please Select
Male
Female
Phone Number
*
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother's Maiden Name (Used for State Immunization Registry Purposes ONLY)
Schedule an Appointment
Aitkin Schedule
*
Brainerd Schedule
*
Breezy Point Schedule
*
Crosby Schedule
*
Marshall Schedule
*
Nisswa Schedule
*
Redwood Falls Schedule
*
Rochester Schedule
*
Slayton Schedule
*
Kemper Drug Schedule
*
Longville Schedule
*
Insurance Information
Do you fill prescriptions at GuidePoint Pharmacy?
Please Select
Yes
No
Do you have health insurance?
Please Select
Yes
No
Health Insurance Name
Insurance Policy ID
Insurance Group Number
Would you like to receive a call from the pharmacy with vaccine pricing information?
Yes
No
COVID-19 Screening
This guidance is intended for screening purposes only. It is not intended for people confirmed or suspected of COVID-19, including persons under investigation.
Do you have any of the following? (check all that apply)
*
Fever or chills
Cough
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
None of the symptoms listed
In the past to weeks, have you: (check all that apply)
*
Been ill or cared for someone who is ill?
Had contact with someone diagnosed with COVID-19
Neither of the above
Health Questionnaire
Are you sick today?
*
Yes
No
Do you have allergies to medications, food, or vaccine?
*
Yes
No
If yes, what allergies do you have?
Do you have a history of Guillain-Barre Syndrome?
*
Yes
No
Have you ever had a serious reaction after receiving an immunization?
*
Yes
No
If yes, what happened?
Are you currently being treated for a long-term health problem such as heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?
*
Yes
No
If yes, what are you currently being treated for?
Are you currently being treated for cancer, leukemia, AIDS, or any other immune system problem?
*
Yes
No
If yes, what are you currently being treated for?
Are you currently taking cortisone, prednisone, other steroids or anti-cancer drugs, or have you had X-ray treatments?
*
Yes
No
If yes, what are you currently being treated with?
Have you ever fainted or felt dizzy after receiving an immunization?
*
Yes
No
Have you had a seizure, brain or nerve problem?
*
Yes
No
If yes, what?
During the past year, have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin?
*
Yes
No
If yes, what did you receive?
Have you received any vaccinations in the past 4 weeks?
*
Yes
No
If yes, what vaccine?
Are you allergic to eggs?
*
Yes
No
Are you allergic to latex?
*
Yes
No
Are you pregnant or is there a chance you could become pregnant during the next month?
*
Yes
No
Additional Questions or Comments:
Submit
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