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  • Booster Dose: Moderna

    **PLEASE NOTE WE NO LONGER HAVE J&J VACCINE IN STOCK AS OF 4/26/2022** Prior to filling this form out you will need photos of your social security card and Medicare Part B (Red, White and Blue Card). If you are commercially insured you will need to provide your Pharmacy Benefits Insurance Card. (It will have "RX BIN & PCN" listed on the card.)
  • If you are wanting a 3rd Dose for Immunocompromised, please use the 3rd Dose Form HERE

     This form is specific to BOOSTER doses for Moderna (0.25ml) 6 months after initial series or 4 months after first booster (50&up or received J&J vaccine booster).  Even if you are changing the vaccine regimen, the eligibility is based off your initial shot e.g. if you got J&J you can boost with Moderna after 2 months.  

    All clinical decisions regarding eligibility and dose will be based on CURRENT CDC Guidelines 

    If you have remaining questions, please  text (316) 348-8517.  Please do not call the pharmacy.  We are doing our very best to keep up with the demands of vaccines, testing, and prescriptions.  If there are not appointments available today, we cannot "squeeze" you in or have you book for one day and show up another.  Thank you for understanding the demands of healthcare currently and challenges in staffing.  Your kindness is appreciated! 

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  • Section II. Questionnaire for Immunization

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  • Section IV. Signatures

    I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Moderna EUA / J&J EUA a copy of which I was provided with this Consent and Release. 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 and Release. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Professional Pharmacy, its subsidiaries, divisions, 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(s). I agree to wait for 15 minutes after my vaccine for observation. I certify that I consulted healthcare provider and they agree that an additional dose is appropriate for me.  

    I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

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  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

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