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  • Mt. Vernon Pharmacy

    900 Cathedral St.; Baltimore, MD 21201

    Voice: 410.539.8030; Text: 410.862-4656; Fax: 410-539-8115 www.mtvernonpharmacy.com

  • Please READ ALL of the information below. 1) This form is only for use for the Pfizer Bivalent Omichron Boosters for patients 12 years and older. No Appointment needed and vaccines will be given on a walk-in basis Monday thru Friday from 10:00 am to 4:00 pm.  DO NOT USE THIS FORM IF YOU STILL NEED A PRIMARY SERIES COVID VACCINATION. Call the pharmacy if you need a primary series vaccination. 2) You will receive a text once we have processed this form. If you come to the pharmacy before we confirm completion of this form, you will most likely have to re-complete the form in the pharmacy.  4) If you have prescription insurance coverage or Medicare (Red, White, Blue card), please upload those crads and bring those cards with you to the appointment. If you do not have prescription insurance coverage, please bring your state identification with you and have your social security number available. If you do not have either of these items, please be assured that you WILL be able to receive the vaccine. 5) Prior to arriving for your vaccine, please READ the following EUA (Emergency Use Authorization) for Recipients/Caregivers for the vaccine that you wish to receive upon arrival:  Pfizer EUA for Recipients. The Pfizer Bivalent Omichron Booster can be administered, even if yoy initially receieved a Moderna Covid Vaccination.

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  • *Persons who have had a severe reaction to a vaccine or currently have an acute febrile illness should not receive a vaccine. I consent to the staff to adminster 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 listed above, concerning the specific manufacturer of the vaccine I am receiving. 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 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.

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  • We will text you once we have uploaded your demographic information into our records. If you go to the pharmacy prior to getting a confirmation text, you will most likely have to fill this same form out in the pharmacy, again. Thank you.

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