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Mpox Vaccination Screening Form
Please answer the questions below to determine your eligibility for the Jynneos Mpox vaccine.
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Have you been diagnosed with Mpox (MPX) since May 17, 2022?
*
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
Name
This field is for validation purposes and should be left unchanged.
