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Mpox Vaccination Screening Form
Please answer the questions below to determine your eligibility for the Jynneos Mpox vaccine.
The requested form is not available at this time.
Have you been diagnosed with Mpox (MPX) since May 17, 2022?
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Yes
No
Are you 12 and older and identify as at least one of the following:
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• Any individual that may be at risk of future exposure to infection with Mpox
• Sexually active bisexual, gay and other men who have sex with men (MSM), including transgender or gender non-conforming individuals
• Any individual regardless of gender or sexual orientation who engage in commercial and/or transactional sex (e.g., sex in exchange for money, shelter, food, or other goods or needs)
Yes
No
Phone
This field is for validation purposes and should be left unchanged.
