COVID-19 Booster Vaccine Appointment ( Moderna /Pfizer only)

COVID-19 Booster Vaccine Appt

Moderna/Pfizer ONLY (All 18+ Adults Now Eligible)
!!!Please read carefully before scheduling your appointment!!!

This form will allow you to make 3rd Dose appointments for the Moderna or Pfizer Booster Vaccine. Active prescription insurance card will be required at time of appointment for clients receiving vaccine. If uninsured than state issued ID copy will be required. Also please don't schedule multiple appointments, if you would like to cancel an appointment use "CANCEL APPOINTMENTS" tab and make sure to cancel appointments at least 24 hours in advance. Please wear short sleeve shirts to your appointment. COVID-19 Booster Dose Appointment should be booked at least 6 months apart from the 2nd Dose Appointment (Do not schedule appointment if this criteria is not met, Pharmacy have the right to cancel your appointment). Please select the earliest possible COVID-19 Booster Dose Appointment so that we can help other clients like you who are looking for COVID-19 Booster. Thanks for your patience.
Which COVID-19 Vaccine Brand did you receive? *

Pfizer Moderna
Have you received your 2nd COVID-19 Vaccine? *

Yes No
Age *
If younger than 65, select the right patient category to proceed
Select the eligible Patient Category For Booster Shot (Multiple Selections Allowed) *

Organ transplant recipients taking immunosuppressive therapy Recipient of stem cell transplants (CAR-T-cell or hematopoietic) within two years or taking immunosuppressive therapy Active/recent cancer treatments Advanced or untreated HIV infection Persons taking medications that weaken the immune system - high-dose corticosteroids (i.e., ≥20mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, TNF blockers, and other biologic agents that are immunosuppressive or immunomodulatory Moderate or severe primary immunodeficiency (e.g., DiGeorge, Wiskott-Aldrich Syndromes) Other Underlying Medical Condition (50 to 64 years old) - include but are not limited to: cancer, chronic heart, lung and kidney diseases, dementia, diabetes, down syndrome, HIV, overweight and obesity, pregnancy, organ transplants, and stroke Other Underlying Medical Condition (18 to 49 years old) - include but are not limited to: cancer, chronic heart, lung and kidney diseases, dementia, diabetes, down syndrome, HIV, overweight and obesity, pregnancy, organ transplants, and stroke Increased risk because of occupational or institutional settling (18 to 65 years old) - including, health care workers, teachers and day care staff, grocery workers and those in homeless shelters or prisons, among others
When did you receive your 2nd Vaccine? *

Month Day Year
Date
COVID-19 Booster Appointment *
Selected Date - Booster Dose

Month Day Year
Date
Days difference between Booster & 2nd Dose Appointment
Booster Appointment should be booked at least 6 months or 180 days apart from the 2nd Dose Appointment. If you are not due, please do not book appointment. Pharmacy have the right to deny your request if you are not 6 months due for the booster appointment.
Vaccine Recipient Name *

First Name Last Name
Date of Birth *

Month Day Year
Phone Number *
Email Address
Note: Confirmation email will go to this email
Vaccine Recipient Physical Address *

Street Address

Street Address Line 2

City State

Zip Code
Gender at birth *
Race *
Ethnicity *
Mother's Maiden Name *
Required for proper vaccine documentation
Primary Vaccine Site *

Left Deltoid Right Deltoid
Primary Care Provider Name

COVID-19 Vaccine Screening Questions *

	Yes	No
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 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 Polysorbate?
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?
6. Have you received any vaccine in the last 14 days?
7. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
8. Do you have a bleeding disorder or are you taking a blood thinner?
9. Are you currently pregnant or breastfeeding?
10. Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
11. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? (If yes, then please wait for at least 90 days before scheduling your appointment)

Consent (check each box below after reading and prior to signing the form) *

	Accept
I understand the benefits and risks of the COVID-19 vaccine as described in the FDA Approval Fact Sheet. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I understand that at this time, the COVID-19 vaccine requires 3rd dose (Booster shot) given at least 180 days apart for Pfizer/Moderna Vaccine. If this is my third dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.
I authorize Crofton Pharmacy to administer Pfizer/Moderna covid-19 vaccine (Booster Shot) to myself.

Signature of Patient to Receive Vaccine: *

Clear
Vaccination card showing first and second dose date and type is mandatory. Please bring active prescription insurance card for clients receiving vaccine and in case of uninsured copy of a state issued ID will be required at time of an appointment.
Should be Empty:

COVID-19 Booster Vaccine Appt

!!!Please read carefully before scheduling your appointment!!!