Are you or your child a patient of Boston Children’s Hospital? Yes No We are sorry Boston Children’s Hospital can only vaccinate current patients at this time. Please visit the CDC website for the most up to date information. Is the patient 16 years old or older? Yes No We are Sorry At this time the COVID-19 vaccines are only available to people age 16 or older. Learn more on the CDC website or complete this form to the notified when the vaccine is available to younger individuals. Does the patient have 2 or more comorbidities? Qualifying comorbidities are: At increased risk: Cancer Chronic kidney disease COPD (chronic obstructive pulmonary disease Down Syndrome Heart condition, such as heart failure, coronary artery disease, or cardiomyopathies Immunocompromised state from solid organ transplant Obesity (body mass index of 30kg/m2 or higher but less than 40kg/m2) Severe Obesity (body mass index greater than 40kg/m2) Pregnancy Sickle cell disease Smoking Type 2 diabetes mellitus Might be at increased risk: Asthma (moderate to severe) Cerebrovascular disease (affects blood vessels and blood supply to the brain) Cystic fibrosis Hypertension or high blood pressure Immunocompromised state (weakened immune system) from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines Neurologic conditions, such as dementia Liver disease Overweight (BMI higher than 25 kg/m2, but less than 30 kg/m2) Pulmonary fibrosis (having damaged or scarred lung tissues) Thalassemia (a type of blood disorder) Type 1 diabetes mellitus Yes No Co-morbidities: We are Sorry At this time the COVID-19 vaccines are only available to people age 16 or older with at least two comorbidities. Learn more on the CDC website or complete this form to the notified when the vaccine is available to other individuals. 1. Patient Information First Name: Last Name: Date Of Birth: Country Of Residence: United StatesAfghanistanAkrotiriAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAshmore and Cartier IslandsAustraliaAustriaAzerbaijanBahamasBangladeshBarbadosBassas da IndiaBelarusBelgiumBelizeBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandClipperton IslandCocos IslandsColombiaComorosCook IslandsCoral Sea IslandsCosta RicaCote IvoireCroatiaCubaCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDhekeliaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland IslandsFaroe IslandsFederated States of MicronesiaFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGaza StripGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJan MayenJapanJerseyJordanJuan de Nova IslandKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMoldovaMonacoMongoliaMontserratMoroccoMozambiqueNamibiaNauruNavassa IslandNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRepublic of the CongoReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSpainSpratly IslandsSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahrainThe GambiaTimor-LesteTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVenezuelaVietnamVirgin IslandsWake IslandWallis and FutunaWest BankWestern SaharaYemenZambiaZimbabwe 2. Contact Information First Name: Last Name: Email Address: Phone Number: It’s okay to leave me a message 3. Submit your request Department Code: Thank you! Someone will be getting in touch with you to finalize your appointment. We are sorry That didn’t work, we may be experiencing technical problems. Please contact 123-456-7890 to schedule your appointment