Select an appointment time (Walk ins are welcome but please fill out information below to expedite process)Choose DateHours-120102030405060708091011Minutes-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMVaccine Recipient NameVaccine Recipient Physical AddressNameDate of Birth* *Gender at birth *Please SelectMaleFemaleRacePlease SelectAmercian Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteEthnicityPlease SelectHispanic or LatinoNot Hispanic or LatinoUnknownVaccine Recipient Phone Number *0 / 10Primary Care Provider NameEmergency Contact NameRelationship to Emergency ContactPlease SelectMotherSisterSiblingBrotherFatherParentGuardianSpouseGrantparentChildFoster ChildStep childCare giverOtherPhone Number of Emergency ContactEmail Address *1. Are you feeling sick today? *YesNoIn the last 10 days, have you had a COVID-19 Test because you had symptoms and are still awaiting your test results or been told by a healthcare provider or health department to isolate or quarantine at home due to COVID-19 infection, exposure, or travel? *YesNoHave you been treated with antibody therapy or convalescent plasma for COVID-19 in the past 90 days (3 months)? *YesNoHave you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies *YesNoHave you received any vaccine in the last 14 days *YesNoAre you pregnant or considering becoming pregnant or breastfeeding? *YesNoDo you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?YesNoDo you take any medications that affect your immune system, such as cortisone, prednisone, or other steroids, anticancer drugs, or have you had any radiation treatments?YesNoDo you have a bleeding disorder or are you taking a blood thinner? *YesNoWhich arm would you like to get the injection on *Left ArmRigth ArmConsent (check each box below after reading and prior to signing the form) *I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.I understand that I will be receiving the vaccination at no cost to me.The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.Please Upload Insurance CardChoose FileNo file chosenDelete uploaded filePlease Upload Supporting Uninsured DocumentChoose FileNo file chosenDelete uploaded fileWhich Covid 19 Vaccine would you like to register for? *Moderna SpikevaxDate Signed * SubmitPlease do not fill in this field.
