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  • MODERNA: COVID Vaccine Consent Form - (Federal Partner)

    * Prior to filling this form out you will need photos of your social security card and Medicare Part B (Red, White and Blue Card). If you are commercially insured you will need to provide your Pharmacy Benefits Insurance Card. (It will have "RX BIN & PCN" listed on the card.) *
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    We are only able to vaccinate based on pulished guidance from the CDC.  This may not be the same information you have heard on the media or via the FDA.  We update our information as quickly as possibly to coordinate with CDC guidelines. 

     

    If you have remaining questions, please text (316) 348-8517.

  • Section I. Personal Information

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  • Section II. Questionnaire for Immunization

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  • Section III. Appointment Scheduler

  • **Vaccine supply is limited. Please keep your appointment .  If you miss an appointment, no doses will be held to guarantee your dose.** 

  • Section IV. Signatures

    I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Moderna EUA a copy of which I was provided with this Consent and Release. 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 and Release. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Professional Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I agree to wait for 15 minutes after my vaccine for observation. 

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  • I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

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  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

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