COVID-19 Vaccine Appointment & Consent Form (Moderna)
COVID-19 Vaccine Dose
First Moderna Dose
Second Moderna Dose
Third Moderna Dose - Booster
Date of Second Dose
Date of Initial Series Completed
Booster Series Attestation
By checking this box, I am attesting that my booster shot will be given 8 months after I will be receiving the second COVID-19 vaccine dose.
First/Second Dose Appointment
Date of Birth
Note: Moderna is only approved for individuals aged 18 and older.
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Prefer Not to Say
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Mother's Maiden Name
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
Relationship to Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.
COVID-19 Vaccine Questions
COVID-19 Screening Questions
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 a
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
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?
This would include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
[note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?
Please check only one of the following:
I HAVE INSURANCE, check this box attesting to completing the medical insurance information below. 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.
I DO NOT HAVE INSURANCE, 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.
Upload a Copy of your Insurance Card
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You will not need to enter in any information below if a picture of your insurance card is uploaded.
Insurance Company Name
Medicare ID Number (from red white & blue card, if applicable)
Social Security Number
Please add if you have insurance but do not have your insurance information available.
I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Gwinnett Drugs, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Gwinnett Drugs to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.
HIPAA Privacy Information & Medical Records
(1) I have acknowledged that I have received the providers Notice of Privacy Practices which may be provided at my request. (2) For Medicare, Medicaid, or Insurance Billing: I authorize this provider to release information and request payment. I understand that the information given by me in applying for payment is correct. (3) I authorize the release of all records to act on this request and I request that the payment of benefits be made on my behalf.
I consent to the above and acknowledge the HIPAA Privacy Information & Medical Records
Should be Empty: