Special Vaccination Clinic Request Form

Special Vaccination Clinic Request Form

If you are eligible to receive a COVID vaccine according to Rhode Island Department of Health guidelines and have a history of anaphylactic reaction to anything, including any foods, insect venom, medications, or latex, you can receive your vaccination at a specialized COVID vaccination clinic at a Lifespan hospital.

To clarify: Anaphylaxis means a severe, potentially life-threatening reaction, not hay fever, lactose intolerance, etc. 

Important: If you have a history of anaphylactic reaction to any other vaccine or injectable therapy (e.g., intramuscular, intravenous, or subcutaneous) we ask that you first consult with your allergist or health care provider before requesting an appointment at our special COVID vaccination clinics.

If you are allergic to any of the components in the vaccine, you will not be able to get the vaccine. Please visit the CDC website at www.cvdvaccine.com for more information.

Please use the form below to request an appointment at a special COVID vaccination clinic.

In the past, I have experienced an anaphylactic (severe allergic) reaction to:

For review