1st & 2nd Dose MODERNA Vaccine Appointment

!!!Please read carefully before scheduling your appointment!!!

Clients who are 18+ are now eligible to get vaccine from Crofton Pharmacy (MODERNA VACCINE IS ONLY AUTHORIZED TO BE USED FOR 18 YEARS AND OLDER CLIENTS - as per CDC guidelines)This form will allow you to make 1st & 2nd Dose appointments at the same time. If younger than 18 years, PLEASE DO NOT SCHEDULE AN APPOINTMENT. Also please don't schedule multiple appointments, if you would like to cancel an appointment use "CANCEL APPOINTMENTS" tab and make sure to cancel appointments at least 24 hours in advance. AGE & IDENTITY PROOF WILL BE REQUIRED DURING YOUR VACCINE APPOINTMENT. MEDICARE PART A & B card required for 65 and older clients. If you have active insurance, please bring Prescription card for vaccination (Medical insurance cards are not accepted by the Pharmacy). Social Security Number is required to lookup your active insurance coverage. WALK INS ARE WELCOME FROM 9.30 AM TO 12 PM MONDAY TO FRIDAY ONLY. Please wear short sleeve shirts to your appointment. Second Dose Appointment should be booked at least 28 days apart from the 1st Dose Appointment. Please select the earliest possible 2nd Dose Appointment so that we can help other clients like you who are looking for COVID-19 Vaccine. Thanks for your patience.

	Yes	No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3a. Have you ever had an allergic reaction to component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. Have 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?
6. Have you received any vaccine in the last 14 days?
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you have a bleeding disorder or are you taking a blood thinner?
9. Are you currently pregnant or breastfeeding?
10. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
11. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? (If yes, then please wait for at least 90 days before scheduling your appointment)

	Accept
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 understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
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.
I understand and agree to share my Social Security Number for Pharmacy processing purposes.

1st & 2nd Dose Vaccine Appointment

!!!Please read carefully before scheduling your appointment!!!