• COVID Vaccine UNIVERSAL FORM

    COVID Vaccine UNIVERSAL FORM

    Please fill out this Immunization Screening and Consent Form for your 1st dose of the Moderna Covid vaccine. NOTE: Completion of this form to the best of your ability will speed up your Covid Vaccine visit. Read this form entirely and fill out the required details below. This form is HIPAA Compliant.
  • Emergency Use Authorization

    The FDA has made the COVID-19 vaccine available under an emergency use authorization(EUA). The EUA is used when circumstances exist to justify the emergency use of drugs and biological products during an emergency, such as the COVID-19 pandemic. This vaccine has not completed the same type of review as an FDA-approved or cleared product. However, the FDA's decision to make the vaccine available under an EUA is based on the existence of a public health emergency and the totality of scientific evidence available, showing that known and potential benefits of the vaccine outweigh the known and potential risks.
  • MODERNA VACCINE CLINICS

    TUESDAYS, WEDNESDAYS, THURSDAYS STARTING OCTOBER 26TH,2021

    AT

    WASHINGTONVILLE PHARMACY

     

     

    This VACCINE is currently BY APPOINTMENT ONLY reserved for patients 18 and over who meet certain criteria.

    After completion, you will get a confirmation email.

    If you have any difficulties, please try a new browser (or incognito mode in your current browser), or try to resubmit.

    If you have questions, please email vaccinewashingtonville@gmail.com. Please do not call the store.

  • You are not eligible for this clinic.

    This clinic is for patients 18 or older.

  • Section I. Personal Information

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    Pick a Date

  • Section II. Questionnaire for Immunization

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  • Please note: IF you answered yes to question#2 or #3, we would recommend that you stay 30 minutes post vaccination as recommended by the CDC. Please bring your Epipen or Epinephrine Injection to the clinic. If yours is expired or do not have one, we will have epinephrine injection on site.

  • Section III. Insurance Information

    ****IT IS VERY IMPORTANT THAT YOU PROVIDE THE INSURANCE INFORMATION ON THIS FORM TO PREVENT DELAYS AT THE TIME OF SCHEDULED VACCINATION****

  • Please bring a copy of your prescription card along with ID to the vaccination site

  • Section IV. Signatures

    In an attempt to reduce paper waste, all legally required documents must be downloaded here. Very limited copies will be available on clinic day.

    Click this to download the Emergency Use Authorization for the Moderna Vaccine.

    Click this to download the Notice of Privacy Practices

    Click this to download the CDC vSafe app flyer

    I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this registration.

    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.

    I certify that I have received, read, and understand the Emergency Use Authorization.

    I certify that I have received the Notice of Privacy Practices.

    I certify that I have received the CDC vSafe informational flyer.

    I certify I am at least 18 years of age. (ID will be required)

    I understand this appointment is for the Moderna vaccine.

    Please type your full name in the box below. You agree your typed full name represents your electronic signature is the legal equivalent of your manual signature on this form.

  • Section IV. Appointment Confirmation

    THE SECOND DOSE OF THE MODERNA VACCINE WILL BE FOUR WEEKS LATER.

     

    **Vaccine supply is limited. Please keep your appointment.**

    Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location.

    If you miss an appointment, no doses will be held to guarantee your dose in the future.

  • 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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