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Kelsey-Seybold Clinic

  • I understand that to schedule for the Pfizer vaccine I must be at least 16 years old.
  • I understand that to schedule for the Moderna or Jansen (J&J) vaccine I must be at least 18 years old.
  • I have not received any COVID vaccinations and am not currently scheduled for a COVID vaccination.
  • I have not had a fever or illness in the last 14 days.
  • I have not tested positive for COVID in the last 30 days.
  • Please acknowledge that you have read the COVID-19 Emergency Use Authorization fact sheets for Pfizer, Janssen (J&J) and Moderna below (clicking the links will open a new tab to the fact sheets):
  • I do not have a history of Guillain Barre Syndrome.
  • I have not received any other vaccinations in the last 14 days.
  • I have not received convalescent plasma for SARS-CoV-2 (COVID-19) in the last 90 days.
  • I have not received monoclonal antibody infusions for SARS-CoV-2 (COVID-19) in the last 90 days.
  • Any minors receiving vaccines should be accompanied by a parent/guardian to provide permission.
  • I understand that protection against COVID-19 may not be effective until at least 7 days after the single dose administration for Janssen (J&J) and may not be effective until at least 7 days after the second dose for Pfizer or Moderna COVID-19 vaccine.
  • I attest that I am at least 16 years old and attest to all items above. You will choose an available location, vaccine type and date/time for your appointment and subsequently provide your demographic and insurance information. The vaccine is provided at no cost to the patient. Vaccine providers can be reimbursed by your health insurance provider for the administration of the vaccine. Available sites and vaccine types are limited.