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Monkeypox Eligibility Form

Allies for Health + Wellbeing is following the state and county guidelines for monkeypox vaccine eligibility. This form will help our staff determine if you currently meet the guidelines for vaccination. If you are currently experiencing symptoms of monkeypox, please contact your healthcare provider. Alert your provider of symptoms prior to arrival at the office. Allies can arrange for testing, if appropriate. If you are eligible to receive the monkeypox vaccine, Allies will contact you within 48 hours to arrange a vaccination appointment. If you do not receive a call from Allies within 48 hours, you may not be eligible for vaccination at this time.

If you have questions about monkeypox testing, treatment or vaccine eligibility, please call our offices at 412-345-7456.

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The following assessment has been created to assist with determining if a person is currently eligible for the monkeypox vaccine. Please read the questions and answer as accurately as possible.
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Question 4B: Do you identify as gay, bisexual, or other man who has sex with men, and/or transgender, gender non-conforming, or gender non-binary, or women who have sex with men who have sex with men?

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