I attest that I am immunocompromised and it has been 28 days or greater since my 2nd dose.
Note: If not immunocompromised, please click “No” for additional screening questions.
Click here to review: Clinical Guidance for Michigan Providers Regarding Additional Dose of mRNA COVID-19 Vaccine.

Yes No

Are you immunocompromised and have received your additional 3rd dose and looking to schedule your booster (4th) dose of a COVID-19 vaccine?

Yes No

What is your age range?

5-11 years 12-17 years 18+ years

Are you immunocompromised and received the J&J/Janssen COVID-19 vaccine for your primary dose?

Yes No

Do you attest that you are eligible for a booster dose based on age, occupation, living conditions, or prexisting conditions.

Yes No

I hearby acknowledge that I will schedule my appointment the appropriate amount of time from the date of my last dose or my appointment may be canceled.

• Pfizer/Moderna - 5 months since last dose.
• J&J/Janssen - 2 months since last dose.

Yes

Was your last dose of the COVID-19 vaccine 2 or more months ago?


Yes No

I hearby acknowledge that I will schedule my appointment the appropriate amount of time from the date of my last dose or my appointment may be canceled.

• Pfizer/Moderna - 5 months since last dose.
• J&J/Janssen - 2 months since last dose.

Yes

I hearby acknowledge that I will schedule my appointment 2 months out from the date of my last dose or my appointment may be canceled.


Yes

By scheduling an appointment for the COVID-19 Vaccine, I hereby acknowledge that I have received and reviewed the COVID-19 Vaccine Fact Sheets.

Yes No

Have you had a severe allergic reaction to a vaccine or injectable therapy?
(IM, IV, Subcutaneous)

Yes No

It is recommended, if you have had a severe allergic reaction to a vaccine or injectable therapy (IM, IV, subcutaneous) you should consult with your healthcare provider before receiving the COVID-19 vaccine. It is required that you be observed for 30 minutes following vaccination.

I acknowledge

Have you been given monoclonal antibodies or convalescent plasma as part of COVID-19 treatment in the last 90 days?

Yes No

Choose your age range:

12-15 years old 16-17 years old 18+ years old

Consent for administration of the vaccine is required for everyone. For those under 18 years old, a parent or legal guardian must provide consent. For 5-15 year olds, an adult must accompany the patient to the clinic. If the adult present is not the parent or legal guardian, an authorization form must be signed by the parent or legal guardian and that paper consent must be brought to the appointment.

The parental authorization form can be found here. You may print the form yourself, or pick one up at a Bronson pediatric practice , Bronson Family Medicine – Helmer Road, or one of these outpatient testing sites.

I will have a parent or legal guardian with me to provide consent.

I will bring an adult that is not a parent or legal guardian with me and I will bring the signed parental authorization form

Consent for administration of the vaccine is required for everyone.For those under 18 years old, a parent or legal guardian must provide consent.

• For 5-15 year olds, an adult must accompany the patient to the clinic.
• For 16-17 year olds, if a parent or legal guardian does not accompany the patient to the clinic, an authorization form must be signed by the parent or legal guardian and patient must bring the paper consent to the appointment.

The parental authorization form can be found here. You may print the form yourself, or pick one up at a Bronson pediatric practice , Bronson Family Medicine – Helmer Road, or one of these outpatient testing sites.

I will have a parent or legal guardian with me to provide consent.

I will not have a parent or legal guardian with me, but I will bring the signed parental authorization form

Which COVID-19 Vaccination have you most recently received?
(Please bring proof of vaccination.)

No Past Dose Pfizer - Dose 1 Pfizer - Dose 2

Which COVID-19 Vaccination have you most recently received?
(Please bring proof of vaccination.)

No Past Dose J&J Moderna - Dose 1 Moderna - Dose 2 Moderna - Dose 3 Pfizer - Dose 1 Pfizer - Dose 2 Pfizer - Dose 3

How many doses of a COVID-19 vaccination have you had?

1 2 3

Bronson Battle Creek Vaccine Clinic (Pfizer)
165 North Washington Avenue Battle Creek, MI 49037
Bronson Mattawan Vaccine Clinic (Pfizer)
52375 North Main Street, Mattawan, MI 49071
Bronson Portage Vaccine Clinic (Pfizer)
6901 Portage Road, Kalamazoo, MI 49002
Bronson South Haven (Wellness Center) Vaccine Clinic (Pfizer)
950 South Bailey Avenue South Haven, MI 49090

Bronson Battle Creek Vaccine Clinic (Pfizer 5-11 year olds)
165 North Washington Avenue Battle Creek, MI 49037
Bronson Mattawan Vaccine Clinic (Pfizer 5-11 year olds)
52375 North Main Street, Mattawan, MI 49071
Bronson Portage Vaccine Clinic (Pfizer 5-11 year olds)
6901 Portage Road, Kalamazoo, MI 49002
Bronson South Haven (Wellness Center) Vaccine Clinic (Pfizer 5-11 year olds)
950 South Bailey Avenue South Haven, MI 49090

Bronson Battle Creek Vaccine Clinic (Pfizer 5-11 year olds Additional Dose)
165 North Washington Avenue Battle Creek, MI 49037
Bronson Mattawan Vaccine Clinic (Pfizer 5-11 year olds Additional Dose)
52375 North Main Street, Mattawan, MI 49071
Bronson Portage Vaccine Clinic (Pfizer 5-11 year olds Additional Dose)
6901 Portage Road, Kalamazoo, MI 49002
Bronson South Haven (Wellness Center) Vaccine Clinic (Pfizer 5-11 year olds Additional Dose)
950 South Bailey Avenue South Haven, MI 49090

Bronson Battle Creek Vaccine Clinic (Pfizer 2nd Dose)
165 North Washington Avenue Battle Creek, MI 49037
Bronson Mattawan Vaccine Clinic (Pfizer 2nd Dose)
52375 North Main Street, Mattawan, MI 49071
Bronson Portage Vaccine Clinic (Pfizer 2nd Dose)
6901 Portage Road, Kalamazoo, MI 49002
Bronson South Haven (Wellness Center) Vaccine Clinic (Pfizer 2nd Dose)
950 South Bailey Avenue South Haven, MI 49090

Bronson Battle Creek Vaccine Clinic (Pfizer 5-11 year olds 2nd Dose)
165 North Washington Avenue Battle Creek, MI 49037
Bronson Mattawan Vaccine Clinic (Pfizer 5-11 year olds 2nd Dose)
52375 North Main Street, Mattawan, MI 49071
Bronson Portage Vaccine Clinic (Pfizer 5-11 year olds 2nd Dose)
6901 Portage Road, Kalamazoo, MI 49002
Bronson South Haven (Wellness Center) Vaccine Clinic (Pfizer 5-11 year olds 2nd Dose)
950 South Bailey Avenue South Haven, MI 49090

Bronson Battle Creek Vaccine Clinic (Moderna 2nd Dose)
165 North Washington Avenue Battle Creek, MI 49037
Bronson Mattawan Vaccine Clinic (Moderna 2nd Dose)
52375 North Main Street, Mattawan, MI 49071
Bronson Portage Vaccine Clinic (Moderna 2nd Dose)
6901 Portage Road, Kalamazoo, MI 49002
Bronson South Haven (Wellness Center) Vaccine Clinic (Moderna 2nd Dose)
950 South Bailey Avenue South Haven, MI 49090

Bronson Battle Creek Vaccine Clinic (Pfizer Additional Dose)
165 North Washington Avenue Battle Creek, MI 49037
Bronson Mattawan Vaccine Clinic (Pfizer Additional Dose)
52375 North Main Street, Mattawan, MI 49071
Bronson Portage Vaccine Clinic (Pfizer Additional Dose)
6901 Portage Road, Kalamazoo, MI 49002
Bronson South Haven (Wellness Center) Vaccine Clinic (Pfizer Additional Dose)
950 South Bailey Avenue South Haven, MI 49090

Bronson Battle Creek Vaccine Clinic (Moderna Additional Dose)
165 North Washington Avenue Battle Creek, MI 49037
Bronson Mattawan Vaccine Clinic (Moderna Additional Dose)
52375 North Main Street, Mattawan, MI 49071
Bronson Portage Vaccine Clinic (Moderna Additional Dose)
6901 Portage Road, Kalamazoo, MI 49002
Bronson South Haven (Wellness Center) Vaccine Clinic (Moderna Additional Dose)
950 South Bailey Avenue South Haven, MI 49090

Bronson Battle Creek Vaccine Clinic (Pfizer Booster Dose)
165 North Washington Avenue Battle Creek, MI 49037
Bronson Mattawan Vaccine Clinic (Pfizer Booster Dose)
52375 North Main Street, Mattawan, MI 49071
Bronson Portage Vaccine Clinic (Pfizer Booster Dose)
6901 Portage Road, Kalamazoo, MI 49002
Bronson South Haven (Wellness Center) Vaccine Clinic (Pfizer Booster Dose)
950 South Bailey Avenue South Haven, MI 49090

Bronson Battle Creek Vaccine Clinic (Moderna Booster Dose)
165 North Washington Avenue Battle Creek, MI 49037
Bronson Mattawan Vaccine Clinic (Moderna Booster Dose)
52375 North Main Street, Mattawan, MI 49071
Bronson Portage Vaccine Clinic (Moderna Booster Dose)
6901 Portage Road, Kalamazoo, MI 49002
Bronson South Haven (Wellness Center) Vaccine Clinic (Moderna Booster Dose)
950 South Bailey Avenue South Haven, MI 49090