Mercer University COVID-19 Vaccine Scheduling

Complete the form below to schedule your first and second dose appointments for the Pfizer-BioNTech COVID-19 vaccine. If you have any questions regarding the vaccine, please call 478-301-7425.

There are no appointments available. Please try to schedule again at a later time.

If no appointments are available, please try to schedule again at a later time.

Select your first-dose appointment:

Location*

Date*

Time*

Your second dose must be administered at least 21 days after your first dose.
Select your second-dose appointment:

Location*

Date*

Time*

Are you at least 16 years old and either work or live in the state of Georgia?

You are not eligible to receive the vaccine at this time.

Have you had an active COVID-19 infection in the past 30 days?

You are not eligible to receive the vaccine at this time.

Have you had any other vaccines in the last 14 days?

You are not eligible to receive the vaccine at this time.

The COVID-19 vaccine should be administered alone, with a minimum interval of 14 days before or after administration of any other vaccines.

Have you ever had a severe reaction to any vaccine or medication?

At this time there are documented risks for someone who has severe allergic reaction to any allergen. You may want to seek guidance from your primary care provider.

To continue scheduling please click “I Understand”.

Do you have any immunocompromising conditions? (HIV-AIDS, Cancer, Lupus, sickle cell disease, recent organ transplantation, etc.)

Data is not currently available to establish vaccine safety and efficacy in these groups.

To continue scheduling please click “I Understand”.

Are you pregnant or breastfeeding?

There are no data on the safety of COVID-19 vaccines in pregnant or lactating people or the effects of mRNA vaccines on the breastfed infant or milk production/excretion. mRNA vaccines are not thought to be a risk to the breastfeeding infant.

To continue scheduling please click “I Understand”.

Do you have an allergy to polyethylene glycol or polysorbate?

You are not eligible to receive an mRNA vaccine. Please try again once a different type of vaccine becomes available.

Have you received monoclonal antibodies for the treatment of COVID-19 in the past 90 days?

You are not eligible to receive the vaccine until 90 days after your monoclonal antibody treatment.

Consent for the Pfizer-BioNTech COVID-19 Vaccine

I am consenting to the administration of the Pfizer-BioNTech COVID-19 vaccine. I understand and agree that:

I have voluntarily chosen to receive the Pfizer-BioNTech COVID-19 vaccination.
Pfizer-BioNTech COVID-19 vaccine has been authorized by the FDA through an Emergency Use Authorization (EUA) which is a mechanism to facilitate the availability and use of medical countermeasures, including vaccines, during public health emergencies such as the COVID-19 pandemic.
I have been provided and have had the opportunity to review fully the EUA Fact Sheet available at https://www.fda.gov/media/144414/download which includes information regarding the vaccine alternatives, expected benefits, risks, and side effects of the Pfizer-BioNTech COVID-19 vaccine. I further understand that I should tell Mercer Medicine as my vaccination provider about all medical conditions including, but not limited to, those medical conditions identified in the Fact Sheet.
There may be side effects from the vaccine that are not listed on the EUA Fact Sheet as each patient responds differently and could have side effects that have not been reported by others.
I have had the opportunity to ask my healthcare provider any questions I may have about the vaccine to my satisfaction.
If I am pregnant or breastfeeding, I am responsible for discussing the vaccine risks and benefits with my healthcare provider(s).
If I have a compromised immune system due to cancer or other disease and/or medications or have received stem cell transplant or solid organ transplant, I am responsible for discussing the vaccine risks and benefits with my healthcare provider(s).
I understand that receiving both doses of the vaccine is important to building full protection against the virus. However, I may decline the second vaccination in the series despite receiving the first.
My vaccination record will be shared with Mercer University and Mercer Medicine, if I am a Mercer University student or I am an employee at Mercer University or Mercer Medicine.
Mercer Medicine will report my vaccination to the Georgia Registry of Immunization Transactions and Services (GRITS) so my healthcare provider will know I have received the vaccine in case I seek treatment.
I understand that I have the opportunity to ask questions of my vaccine provider and will not receive the vaccine until my questions have been answered satisfactorily.

This consent must be signed and provided to Mercer Medicine at your first appointment. You may either 1) print the following file: Pfizer-BioNTech Consent Form and take a signed copy with you to your first appointment or 2) sign a hard copy of the consent form at your first appointment.

What is your affiliation with Mercer?

Mercer ID

First Name*

Middle Name

Last Name*

Birth Month*

Birth Day*

Birth Year*

Gender*
Female
Male

Email*

Phone Number*

Street*

City*

State*

Zip*

Primary Language*
English
Other

Language*

Ethnicity*

Race*

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