• APPOINTMENTS for BOOSTER SPECIAL ANNOUNCEMENT

     

    The Moderna Bivalent vaccine is in limited supply and an apppointment might not be available until late September 2022. The Pfizer bivalent vaccine has a large supply and many appointments available. The CDC recommends receving either vaccine regardless of what you may have received before. If you complete this form and now appointments are available please give us call at 719-395-2481 and we can schedule you for a Pfizer vaccine instead. 

    This vaccine provides additional protection to several variant stains of the Omicron COVID virus. This vaccine recommended 2 months after your last COVID vaccine and for those 18 years and older. The original (monovalent) vaccine is no longer approved as a booster dose. In order to minimize waste, you might be asked to move your appointment if needed.

     

  • Moderna COVID Vaccine Consent Form - Buena Vista Drug

    Moderna COVID Vaccine Consent Form - Buena Vista Drug

    * Please fill out the required details below
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  • Section I. Personal Information

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    Pick a Date

  • Emergency Contact Information

     

  • The CDC approved a BIVALENT booster dose for ages 18+ when the last vaccine was received at least 2 months ago. 

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    Pick a Date
  • Section II. Questionnaire for Immunization

    The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine today. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions may be asked. If a question is not clear, please ask your healthcare provider to explain it.

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  • Section III. Appointment Scheduler

  • Section III. 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.

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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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  • Section IV. Insurance/Billing Information

  • Medicare Part B Insurance Card Information

    Please input each of the following for your insurance card
  • CO Medicaid

    Please enter your CO Medicaid ID Number
  • Insurance Card Information

    Please upload a picture or input each of the following for your insurance card
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  • OR

  • Uninsured

    Even if you are uninsured you are still able to receive the COVID vaccine an no cost to you.
  • Section V. Appointment Scheduling

    Please read the following notices. Once you submit you will be redirected to the scheduling page to book your appointment.

  • *VACCINE SUPPLY IS LIMITED. PLEASE KEEP YOUR APPOINTMENT OR CALL IF YOU NEED TO CANCEL OR CHANGE IT. ADDITIONALLY, DUE TO VACCINE REQURIEMTNS; WE MAY CALL YOU TO SEE IF YOU CAN COME IN EARLIER, LATER, GO TO A DIFFERENT LOCATION OR RESCHEDULE TO A DIFFERENT DAY. IF YOU MISS AN APPOINTMENT, NO DOSES WILL BE HELD TO GUARANTEE YOUR DOSE.*

     

    ****IF YOU SCHEDULED TO RECIEVE THE VACCINE AT ANOTHER LOCATION. PLEASE CONTACT THAT ORGANIZATION TO CANCEL YOUR APPOINTMENT ONCE YOU RECEIVE YOUR FIRST DOSE AT OUR PHARMACY****

  • 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.

  • For Immunizing Staff Use Only

    Vaccine product: Moderna COVID19 Vac. (bivalent/monovalent)

    Exp                                  Lot                                     

    Administered by(print)                                                         

    Signature:                                                                          

    EUA Published Date monvalent (8/31/22);bivalent (8/31/22)

    Dose number 1st / 2nd / booster

    NDC see attached back tag

    Route IM Volume 0.5ml Site L.Arm / R.Arm

    Credentials PharmD / Intern Pharm. / PhTech

    Administration Date                                   

    EUA given to patient (date)                        

     

     

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