Booster-Moderna or J&J

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!
Feel free to follow us on Social Media for the most current updates!
Email *
example@example.com
Select an Appointment Day/Time *
Patient's Legal Name (as it appears on your Pharmacy or Medical Insurance Card): *

First Name Ml Last Name
Date of Birth: *

Month Day Year
mm/dd/yyyy
Address: *

Street Address Line 2
Age: *
65
Cell Phone Number *
Please enter a valid phone number.
Biological Gender: *

Male Female
Cell Phone Number:
Race: *

African American American Indian Asian Caucasian Native Hawaiian/Other Pacific Islander Prefer not to answer Other
Ethnicity: *

Hispanic or Latino Non Hispanic/Latino Unknown Prefer not to answer
Which arm would you like your vaccine administered in? (Using your dominant ar will help reduce soreness due to more movement.) *

Left Right
What dose of COVID-19 vaccine will this be? *

First Dose Second Dose First Booster Dose (approved 10/21/2021) Second Booster Dose (approved March 2022)
Which Vaccine have you previously gotten? *(Please note, that we may verify your vaccine history with the state registry) You will need to bring your card to the pharmacy. *

Yes, J&J Janssen Yes, Moderna Yes, Pfizer
Which Booster are you requesting? *

Moderna 0.25 ml
When did you receive your last dose of any Covid Vaccine? *

Month Day Year
Date
Primary or Referring Care Doctor: *
Doctor City/State:
Please verify which of the following applies to you. Please note that your selection will become part of your formal medical record and by signing this form you are attesting *

65 years or older 18+ living in a long term care setting 18+ with underlying medical conditions (cancer, Chronic Kidney or Liver Disease, Chronic lung issues, Dementia, Diabetes, Down Syndrome, Heart conditions, HIV, Mental Health Disorders, Obesity, Pregnancy, Sickle Cell, Smoker (currrent or former), Transplant recipient, Stroke, Substance Abuse Disorders) 18+ work/live in a high risk setting I am severely immuncompromised by CDC Definition so I need a 3rd Full Dose (Go to that form at wichitapharmacy.com N/A
My signature below is a self-attestation that I qualify to the eligibility of a booster vaccine. I understand this form will become part of my permanent medical record and I have represented myself and my vaccine history truthfully. *

Clear
Patient's Social Security Number *
111-11-1111
Section II. Questionnaire for Immunization

Please select the correct option below: *

	Yes	No	Don't know or N/A
COVID-19 Screening Questions: In the past two weeks, have you tested positive for COVID-19 or are you currently being monitored for COVID-19?
In the past two weeks, have you had a known exposure with anyone who tested positive for COVID-19?
Have you had a new onset of fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?
Questionnaire for Immunization: Do you feel sick today? (If filling in advance you understand you will need inform the vaccinator on the day of your vaccine of any changes)
Do you have an allergy to medications, foods, or any vaccines (eggs, gelatin, thimerosal, neomycin, gentamicin, latex, aluminum, preservatives, baker's yeast, etc.)?
Do you carry an EpiPen?
Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
Have you ever had a serious reaction or fainted after receiving any vaccination?
Have you ever had a seizure, brain disorder, or Guillain-Barre Syndrome?
For women: Are you pregnant or are you planning on becoming pregnant during the next month?

Please specify the allergy from Q2:
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.
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 yo) and acknowledgement of our Privacy Practices. *

Clear
Please take or upload pictures of front & back of insurance card for billing purposes (Medicare Part B Card, Commerical Insurance or Medicaid Card). (If you do not have insurance, we love plants and pets--feel free to share an image or utilize your drivers license) *

Please do not skip this step. Your reservation will require this information.
Cancel of
If insured by Medicare, what is your MBI number on your red, white, and blue card? If not insured by Medicare re-enter your SS#
example: 1EG4-TE5-MK73
Type a question *

I authorize the pharmacy to bill my insurance on my behalf for the immunization
If uninsured, you must check the box below to attest that the following information is true and accurate:

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan
In order to have your vaccine administration fee paid for by the United States Health Resources & Services Administration's COVID-19 Program for uninsured patients, please select to provide one of the following: *

Social Security Number State identification number and state of issuance Driver's license number and state of issuance
Social Security Number *
111-11-1111
State identification number and state of issuance *
Driver's license number and state of issuance *
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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Booster Dose: Moderna