MODERNA /PFIZER BOOSTER SHOT FORM

Type of Shot*

Pfizer Bivalent Booster Dose (NEW)Moderna Bivalent Booster Dose (NEW)Pfizer Booster Dose (Ages 5-11)

Would you like to get a flu shot at the same time as your COVID Vaccine appointment ? CDC states both can be administered together.*

YesNo

Would you like to get free at-home covid tests (upto 8 if covered by insurance)*

YesNo

Choose your appointment time*

Name*

First NameLast Name

Birthdate*

Gender*

FemaleMaleOther

Cell Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you received the first two doses of the vaccine?

YesNo

Date of your last COVID Vaccination*

What allergies do you have? *

Have you had a serious reaction after receiving a vaccination?*

YesNo

Have you had a seizure or a brain or other nervous system problem or Guillain barre ?*

YesNo

Have you received any vaccinations in last 4 weeks?*

YesNo

Have you been treated with antibody therapy specifically for COVID-19 (monoclonal antibodies or convalescent plasma)?*

YesNo

Are you pregnant?*

YesNo

Do you have a history of fainting, particularly with vaccines?*

YesNo

If you have MEDICARE (RED WHITE AND BLUE CARD) - please enter your ID number:

Signature*

Clear

Consent:

I understand the benefits and risk of the vaccine(s) being administered and have received a copy of a current vaccine infromation sheet (which will be emailed to you upon submission of this form). I understand that I can ask questions prior to administration of the vaccine and will review the VIS that will be sent to me via email after form submission. I on behalf of my heirs, executors, personal representatives, agents, successors, and assigns herby agree to release, indemnify and hold harmless Milltown Pharmacy, its subsidiaries, divisons, 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. I certify that I am at least 18 years old and here by give consent to pharmacists of Milltown Pharmacy to adminsiter the vaccine. I agree to wait near the vaccination locatio nfor approximately 15 minutes for obeservation by the pharmacist.

I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose
of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my
child's immunization history.
I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools,
licensed child care centers, colleges, public health agencies, health insurance companies, and others as permitted by New
Jersey Law at N.J.S.A. 26:4-131 et seq. and rules at N.J.A.C. 8:57-3.
I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department,
or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone number
listed above.
There is no cost to participate in this program.

COVID-19 VACCINE FORM