State of Missouri Bureau of Immunizations
COVID-19 Vaccination Screening and Consent Under Emergency Use Authorization
Adapted by Kilgore's Medical Pharmacy. Your responses will be used to complete the State's recommended form.
Please complete the following information for the person receiving the COVID-19 Vaccine.
The first sellector will determine if you are eligible. This form is to schedule a First Dose of Moderna Vaccine.
You must be at least 18 to receive the Moderna Vaccine.
If you see this message, you are not currently eligible for the vaccine in Missouri.
For specific information about the populations within each phase/tier, visit MOStopsCovid.com.
The State of Missouri is conducting a phased roll-out of the COVID-19 vaccine prioritizing saving lives and is dictated by vaccine availability. This form will gather information about you, including your employment and health risks to determine your eligibility and properly schedule your vaccination appointment. All your information will be kept confidential to the extent allowed by law. By signing below you are self-certifying that everything you have indicated on this form is true and that you fall into the phase/tier indicated above.
Specific information about the populations within each phase/tiers can be found on the MOStopsCovid.com website.
Clinical Judgement – all vaccinators are encourage to use their clinical judgement/discretion to authorize a vaccine for any individual, regardless of where they may otherwise fall in the prioritization process.
Sorry, this form is only for first dose appointments. If you are looking for a second dose, please contact the provider who gave you your first dose. If your provider was Kilgore's, your second appointment is at the same time as your first appointment 28 days later. You can find your second appointment on your immunization card.
The Public Readiness and Emergency Preparedness Act (PREP Act) authorizes the CICP to provide benefits to certain individuals or estates of individuals who sustain a covered serious physical injury as the direct result of the administration or use of the covered countermeasures. The CICP can also provide benefits to certain survivors of individuals who die as a direct result of the administration or use of covered countermeasures identified in a PREP Act declaration. The PREP Act declaration for medical countermeasures against COVID-19 states that the covered countermeasures are any antiviral medication, any other drug, any biologic, any diagnostic, any other device, or any vaccine used to treat, diagnose, cure, prevent, or mitigate COVID-19, the transmission of SARS-CoV–2 or a virus mutating from SARS-CoV-2, or any device used in the administration of and all components and constituent materials of any such product. Information about the CICP and filing a claim is available by calling 1-855-266-2427 or visiting https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccine or https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/moderna-covid-19-vaccine
Moderna COVID-19 Vaccine EUA https://www.fda.gov/media/144638/download
Pfizer COVID-19 Vaccine EUA https://www.fda.gov/media/144414/download
Johnson & Johnson COVID-19 Vaccine EUA https://www.fda.gov/media/146305/download
By signing below, I acknowledge and agree that I have received Kilgore's Medical Pharmacy's privacy practices electronically at https://kilgoresrx.com/wp-content/uploads/2021/01/Hipaa-privacy-practices-2021-all-stores.pdf and that I may obtain a copy at my appointment upon request.