MODERNA /PFIZER BOOSTER SHOT FORM

Type of Shot *

Pfizer Booster Dose Moderna Booster Dose

Interested to learn about our other services?

Men's Health Telemed visits & Prescription services Dietitian Services (covered under Horizon insurance)

Choose your appointment time *

Name *

First Name Last Name

Birthdate *

Gender *

Female Male Other

Cell Phone Number *

Please enter a valid phone number.

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Have you received the first two doses of the vaccine? *

Yes No

Date of your second Vaccination *

What allergies do you have? *

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

Yes No

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

Yes No

Have you received any vaccinations in last 4 weeks? *

Yes No

Are you pregnant? *

Yes No

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

Yes No

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

Pharmacy Insurance Card Front Photo (PLEASE BRING YOUR CARD)

Pharmacy Insurance Card Back Photo (PLESE BRING YOUR CARD)

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.

COVID-19 VACCINE FORM