RSV Clinic

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Parent Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
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Has your insurance changed since your last office visit?* This field is required.
YESNO
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Please upload an image of your new insurance card.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Child {childNumber}'s Name* This field is required.
First
Last
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{childName:first}'s Date of Birth* This field is required.
Month
Day
Year
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How old will {childName:first}'s on the day of the appointment?
Please Select
Please Select
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
7 months
8 months and older
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Calculation
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Did the mother of {childName:first} receive the RSV vaccine while pregnant?
YESNO
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Was {childName:first} born within 14 days of the mother receiving the RSV vaccine?
YESNO
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Has {childName:first} received a previous dose of the RSV vaccine in the current RSV season (for example, in the NICU)?
YESNO
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Has {childName:first} ever had an allergic reaction to a vaccine or injectable medication?
YESNO
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Has {childName:first} had an adverse reaction to other vaccines in the past?
YESNO
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CDC Vaccine Information Statement: Respiratory Syncytial Virus (RSV) Preventive AntibodyPlease read the "Immunization Information Statement" in the PDF viewer on the next page. If you still have questions or concerns after reviewing this material, please contact our office.
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Acknowledgment of Informed Consent* This field is required.By signing below, I, {parentName}, acknowledge that: {consentText} I understand the benefits and risks indicated and ask that the vaccine(s) be given to {childName} for whom I am authorized to make this request.
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Thank you for your inquiry regarding the RSV vaccine for {childName:first}. Based on the current guidelines and the information provided, it appears that {childName:first} does not qualify for the RSV vaccine at this time.

If your child is 8 months - 19 months old and meets the high risk criteria, please contact our office to schedule an appointment with your child's pediatrician to discuss and receive the RSV vaccine. The high risk criteria is available in the RSV vaccine FAQs on our website - www.piedmontpediatrics.org

If you have any concerns or believe that this information may not be accurate, please don't hesitate to reach out to our office by sending a portal message to your child's pediatrician. We are here to assist you with any questions you may have and to provide further clarification.
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Please schedule an appointment Date and Time* This field is required.Your child MUST be 8 months of age or younger to receive the RSV vaccine
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apptString
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primaryEntry
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ChildNumber
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apptDateTime
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After pressing Submit below you will be taken to a new form entry for child # {nextChildNumber} of {howManyChildren}
Should be Empty: