• Moderna COVID-19 Vaccine Consent Form

    18 years and older
  • First Booster Dose: Booster shots have been approved for Pfizer as long as it has been more than 5 months since your second dose. 

     

    Second Booster Dose:  A second mRNA booster dose could benefit people ages 50 years and older, as they are at increased risk for severe COVID-19. People ages 50 years and older may choose to receive a second booster dose using an mRNA vaccine if it has been at least 4 months after the first booster dose, for a total of 4 doses. 

     

    Moderately to severely immunocompromised:  CDC recommends at 3 dose primary series at 3 and 4 week intervals for everyone 18 and older.  The first booster at 3 months after the 3rd dose and a second booster 4 months after the first booster.

    Moderate and severe immunocompromising conditions and treatments include but are not limited to:

    • Active treatment for solid tumor and hematologic malignancies
    • Receipt of solid-organ transplant and taking immunosuppressive therapy
      Receipt of chimeric antigen receptor (CAR)-T-cell therapy or hematopoietic cell transplant (HCT) (within 2 years of transplantation or taking immunosuppression therapy)
    • Moderate or severe primary immunodeficiency (e.g., DiGeorge syndrome, Wiskott-Aldrich syndrome)
    • Advanced or untreated HIV infection (people with HIV and CD4 cell counts
      Active treatment with high-dose corticosteroids (i.e., ≥20 mg prednisone or equivalent per day when administered for ≥2 weeks), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor necrosis factor (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory

     

    This form is for Moderna which is approved for those 18 years and older.  This form is for 1st, 2nd, 3rd and booster doses.  You will be screened upon checkin for which dose you are receiving.

  • **Disclaimer**  If there are no time slots available, we have no vaccine.  Please do not call the store and just check back later for future availability.  Thank you!

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