First Dose COVID-19 Vaccine Appointment Form (Moderna)
In order to receive the Moderna vaccine, you must be at least 18 years of age at the time of your first dose. You may schedule both appointments now to reserve your doses. Please Note: We currently only have the Moderna vaccine in stock. Vaccination consists of 2 doses 28 days apart (for Moderna brand). All appointments are for Volunteer Pharmacy, located at 2559 Willow Point Way, Knoxville, TN 37931.
First Dose Appointment. Select an appointment time (gray boxes indicate unavailable times). We do not administer vaccines before 9am or after 4pm. Do not arrive at the pharmacy before 9am.
Vaccine Recipient Name
Vaccine Recipient Physical Address
Street Address Line 2
Postal / Zip Code
Date of Birth
Date Picker Icon
Gender at birth
Vaccine Recipient Phone Number
(000) 000-0000 format
Emergency Contact Name
Relationship to Emergency Contact
Phone Number of Emergency Contact
(000) 000-0000 format
The vaccine is available to anyone at no cost 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.
For insured patients, please bring your prescription coverage card including YOUR MEDICARE (RED, WHITE, AND BLUE) CARD OR SEQUENCE OF LETTERS AND NUMBERS. For uninsured patients, please have your social security number available.
Please do not arrive early for your appointment. Appointment times are scheduled to assist in daily vaccine allotment. Please understand that due to scheduling multiple people per time slot, you may have an extended wait time to receive your vaccine. Please bring the following to your appointment: your vaccine card given to you at the time of your first vaccine dose, copy of your paperwork, Medicare or prescription insurance card, driver's license, and any verification of employment if necessary.
Please verify that you are human
Submit Consent Form (required)
Should be Empty: