• Moderna COVID-19 Vaccine Consent Form

  • Complete this online form prior to arriving for your COVID vaccine.

  • PLEASE READ CAREFULLY

    The CDC has approved an additional booster dose for certain individuals. 

    Moderna

    For individuals who received a Moderna COVID-19 vaccine or Pfizer COVID-19 vaccine:

    1. All patients age 50 years and older are eligible for a second booster dose at 4 months or more after their initial booster was completed.

    2. Patients 18 years and older with certain immunocompromising conditions are also eligible for a second booster 4 months or more after their first booster was completed. See reasons for booster below for eligibility. 

     

    Janssen / Johnson & Johnson

    Patients aged ≥18 years who received a single dose Janssen/Johnson & Johnson primary series (1 dose) and booster dose at least 4 months ago may now receive a second booster using an mRNA vaccine,Moderna or Pfizer Covid-19 Vaccine.

    Click Herefor more information on who is eligible for a COVID-19 Vaccine Booster Shot

    1. For information regarding the vaccine refer to the link below for the Emergency Use Authorization (EUA) Fact Sheet. 

    Moderna EUA Fact Sheet

    2. Select your 15 minute appointment time and complete the form.

    3. Make sure a "thank you" screen appears after you click submit

     

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