Immunization Scheduling and Questionnaire
What GuidePoint Pharmacy location would you like to receive your immunization(s)?
*
Please Select
Aitkin
Brainerd
Breezy Point
Crosby
Kemper Drug
Longville
Marshall
Redwood Falls
Slayton
Check immunization(s) you wish to receive:
*
COVID-19
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.**
Vaccine Elgibility
Please select any of the criteria that you match below. If you do not meet the criteria for COVID-19 vaccination, you may fill out your information and we can text or call you once you meet the criteria set forth by the Minnesota Department of Health.
I am 65 years or older
I have a chronic health condition (ex. )
I meet neither of the above criteria
**At this time you are not eligible to receive the COVID-19 vaccine. You may submit your information and receive a call or text when the Minnesota Department of Health has expanded the persons eligible to receive the vaccine***
Meet 1b criteria
yes
no
Name
*
Date of Birth
*
 /
Month
 /
Day
Year
2 digit month, 2 digit day, 4 digit year
1
Gender
*
Please Select
Male
Female
Phone Number
*
Format: (000) 000-0000.
Would you like to receive a text or a call for an appointment reminder or when you meet criteria for the COVID-19 vaccine?
Yes, Text me
Yes, Call me
No
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
*
Aitkin COVID-19 Schedule
*
Brainerd Schedule
*
Brainerd COVID-19 Schedule
*
Breezy Point Schedule
*
Breezy Point COVID-19 Schedule
*
Crosby Schedule
*
Crosby COVID-19 Schedule
*
Marshall Schedule
*
Marshall COVID-19 Schedule
*
Redwood Falls Schedule
*
Redwood Falls COVID-19 Schedule
*
Slayton Schedule
*
Slayton COVID-19 Schedule
*
Kemper Drug Schedule
*
Kemper Drug COVID-19 Schedule
*
Longville Schedule
*
Longville COVID-19 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
BIN Number
PCN Number
Insurance Policy ID
Insurance Group Number
Would you like to receive a call or text from the pharmacy with vaccine pricing information?
Yes, text me
Yes, call me
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.
In the past two weeks have you tested positive for Covid-19 or are you currently being monitored for COVID-19?
Yes
No
**Please wait until your COVID-19 infection or observation is completed prior to receiving any vaccines**
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
**If you suspect a COVID-19 infection please reach out to your healthcare provider. It is recommended to wait until you are no longer ill prior to receiving a vaccine.**
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 had a severe allergic reaction (e.g., anaphylaxis) to a previous dose of COVID-19 vaccine?
*
Yes
No
If yes, what happened?
**Call the pharmacy to determine if you should receive a 2nd dose of COVID-19 vaccine.**
Have you received monoclonal antibodies or convalescent plasma as part of COVID-19 treatment in the past 90 days?
*
Yes
No
If yes, what was the reaction?
*
**It is recommended for you to wait 90 days after you have received monoclonal antibodies or convalescent plasma for COVID-19 Treatment. Please schedule appointment at a later date**
Have you ever had a serious reaction (e.g. anaphylaxis) after receiving an immunization or injectable therapy (medications administeredinto the muscle, into the vein, or under the skin)?
*
Yes
No
If yes, what happened?
**It is STILL recommended for you to receive the COVID-19 vaccine even if you have had a severe reaction to injectable therapy in the past. You will be asked to stay for 30 minutes for observation after receiving your COVID-19 vaccine**
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 2 weeks?
*
Yes
No
If yes, what vaccine?
**It is NOT recommended to have another vaccine two weeks before or after receiving COVID-19. Please schedule an appointment that is at least 2 weeks from when you received your last non-COVID 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:
Wait time
15
30
Submit
Should be Empty: