Monkeypox Vaccine Interest Form

Monkeypox Vaccine Interest Form

Westside Family Healthcare has a limited supply of monkeypox vaccine to give by appointment only. Please complete this form and we will call you to schedule an appointment for your vaccine.

First Name*

Last Name*

Date of Birth*

Are you a Westside patient?*

Yes / Si

Preferred Westside Location for Vaccine Appointment*

4th Street - Mondays 1-8pm

Northeast - Wednesdays 1-8pm

Newark - Mondays 1-8pm

Bear - Thursdays 4-8pm

Dover - Wednesdays 1-8pm

None of these days or times work for me (please not in the comments below which day of the week or time you prefer)

Phone Number*

Phone

The following are risk factors for monkeypox.*

Anyone who has multiple sex partners in the past 21 days
HIV positive
Taking PrEP for HIV
Gay, bisexual and transgender or nonbinary persons having sex with men
Females having sex with gay, bisexual, non-binary, or transgender males
Sex workers (of any sexual orientation/gender)
All staff at establishments where sexual activity occurs (e.g., bathhouses, saunas, sex clubs)
Health care workers who are providing direct patient care including laboratory staff that handle monkeypox specimens

If you have any of these risk factors, or feel you are at higher risk for monkeypox, select yes you would like a monkeypox vaccine.

Yes, I would like the monkeypox vaccine / Si, quiero la vacuna contra la viruela símica

No, I am not at higher risk / No, no estoy en alto riesgo

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