*MODERNA* Covid-19 Vaccination Consent Form

The vaccine is being provided at no cost by the government. Your insurance will be charged for the costs of administering the vaccine.
Insurance Type: Please also upload a picture of the front and back of your insurance card below if possible to ensure smooth data entry and processing. *

Private Insurance Medicare Medicaid/Medical Assistance No Insurance
Private Insurance Information:

RX BIN #   # # # # # #*
RX PCN #  *
RX Group #   *
RX ID #   *
Medicare ID # XXXX - XXX - XXXX*
*Note: This is your NEW Medicare Unique ID number.
Do NOT input your Social Security Number (old Medicare ID) here.
Last 4 digits of Social Security Number (for Medicare ID verification): *
Medical Assistance # (11 digits long): ###########*
If uninsured, please provide your driver's license ID # (ex. C-111-222-333-444) or social security number (ex. 999-88-7777) for HRSA Covid-19 uninsured billing. *
FRONT of Insurance Card

This is not required, but will ensure that there will be fewer issues with patient and vaccine processing.
Cancel of
BACK of Insurance Card

This is not required, but will ensure that there will be fewer issues with patient and vaccine processing.
Cancel of

CONSENT
Moderna Covid-19 Vaccine EUA Patient/Caregiver Fact Sheet
*Persons who have had a severe reaction to a vaccine or currently have an acute febrile illness should not receive a vaccine. I certify that all information provided on this form is correct. I consent to the staff to administer the vaccination(s) mentioned below. I understand that this vaccine has been authorized by the FDA under an Emergency Use Authorization and I have reviewed the fact sheet that has been provided to me concerning the specific manufacturer of the vaccine I am receiving today. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of receiving this vaccine and choose to assume this risk. I fully release and discharge the pharmacist and the pharmacy, its affiliations and their officers and employees from any illness, injury, loss, or damage that may result there from. I acknowledge that I have received a copy of the pharmacy's privacy policies according to HIPAA. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy. I consent the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any vaccinations received to the appropriate state vaccine registry. I am aware that an immunization certified student pharmacist might be administering this vaccine. I understand that COVID-19 vaccination doses are limited, and if I miss my appointment, I am NOT guaranteed a vaccination at another time. I also understand that Finksburg Pharmacy will only hold my 2nd vaccination dose for 42 days after the date of my first dose, and if I am unable to schedule my booster in that time frame, I am NOT guaranteed a booster vaccination appointment at another time. If obtaining my third mRNA dose, I self-attest that I have been notified of the eligibility requirements and I meet one or more of the immunocompromised criteria. I agree to wait near the vaccination area for a minimum of 15 minutes or as otherwise instructed by the pharmacist so that I may receive treatment if I begin to feel unwell.
Signature: *

Use your mouse or touchscreen to electronically sign your name. Clear
Please bring your Driver's License (or other form of valid photo ID) to your appointment for proof of identity.
**For Clinic Use Only**
Dosage

0.5ml (Moderna or J&J) 0.25ml (Moderna booster)
Lot Number:
Expiration Date:

Month Day Year
Date
Clinic Location

Finksburg Pharmacy Other
Administered By/Credentials

Raimon Cary Min-li Cary Elisabeth Setzler Other
Name
Pharmacist License Number
EUA Given

YES
Date of Appointment/EUA Given

Month Day Year
Should be Empty:

MODERNA COVID-19 Vaccination Consent Form

Screening Questions

The vaccine is being provided at no cost by the government. Your insurance will be charged for the costs of administering the vaccine.

CONSENT

Please bring your Driver's License (or other form of valid photo ID) to your appointment for proof of identity.

For Clinic Use Only

MODERNA COVID-19 Vaccination Consent Form

Screening Questions

The vaccine is being provided at no cost by the government. Your insurance will be charged for the costs of administering the vaccine.

CONSENT

Please bring your Driver's License (or other form of valid photo ID) to your appointment for proof of identity.

**For Clinic Use Only**

For Clinic Use Only