SEMC COVID-19 Vaccine List

Sleepy Eye Medical Center is currently collecting information for patients who are 12+ years of age or older and interested in receiving the COVID-19 vaccine. Once you complete our form, please refrain from contacting us. We will use this information to contact you for scheduling. Sleepy Eye Medical Center has Pfizer, Moderna and Johnson & Johnson vaccines. Pfizer and Moderna are two-dose series vaccines. Pfizer is given 21 days apart and Moderna is given 28 days apart. Pfizer is an option for individuals who are *12+ years of age. (*Parental/guardian consent is required for 12-17 year olds.) Johnson & Johnson is a single-dose vaccine. Please select your preference in the form below. We now offer Pfizer booster shots for those who qualify. Current qualifying factors include: 65+ years or older, residents in long-term care settings, people aged 18-64 with underlying medical conditions, people aged 18-64 who are at an increased risk for COVID-19 exposure and transmission because of occupational or institutional setting (medical workers, childcare workers, teachers, emergency personnel), must also be 6+ months out from second COVID-19 (Pfizer) vaccine.

Patient Legal Name*
First Last
Name of Parent/Guardian
First Last
*For individuals who are12-17 years of age
Date of Birth*

00/00/0000
Vaccine Preference*
- Select All
- MODERNA (two-dose vaccine, given 28 days apart; option for 18+ years)
- MODERNA BOOSTER (must be 6+ months out from second Moderna vaccine and meet qualifying factors listed below)
- PFIZER (two-dose vaccine, given 21 days apart; option for 12+ years)
- PFIZER BOOSTER (must be 6+ months out from second Pfizer vaccine and meet qualifying factors listed below)
- JOHNSON & JOHNSON (single-dose; option for 18+ years. *NOTE: SEMC will not administer J&J boosters. Please contact local Public Health, if interested.)
Please select how you qualify:*
- 65 years of age or older
- People aged 18 or older with underlying health conditions
- Frontline worker
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Email
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SEMC COVID-19 Vaccine List

SEMC COVID-19 Vaccine List

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