FAR HILLS MODERNA /PFIZER BOOSTER SHOT FORM

Type of Shot *

Moderna Booster Dose (NEW - 2024-2025)Pfizer Booster Dose (NEW - 2024-2025)High Dose Flu Shot ( for seniors above 65 years of age)Flu Shot (Age between 7 and 64 years)Shingrix ( Shingles Shot - first or second dose)RSVPrevnar -13 ( Pneumonia Shot)Prevnar - 20 (Pneumonia Shot)Pneumovax -23 ( Pneumonia Shot)Tdap (Boostrix) - Tetanus ShotWhooping Cough ( Pertussis) Shot

Interested to learn about our other services?

ED Telemed visits with prescription deliveryDietitian Services (may be covered under insurance)Pharnacogenomics ( YOUR Genetic Profile's effect on your Meds)Micronutrient Testing ( To know the EXACT level of micronutrients in your body)Hormone Therapy consults with Robert

Name*

First NameLast Name

Birthdate*

Appointment

Gender*

FemaleMaleOther

Cell Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Based on current CDC recommendations, are you eligible for booster dose?

YesNo

Have you received the first two doses of the vaccine?

YesNo

Date of your second Vaccination

What allergies do you have? *

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

YesNo

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

YesNo

Have you received any vaccinations in last 4 weeks?*

YesNo

Are you pregnant?*

YesNo

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

YesNo

Have you received a blood transfusion, steroid therapy, radiation or anticancer drugs in recent weeks or are you on any of the above therapies currently?*

YesNo

Do you have Medicare?

YesNo

What is your Medicare ID Number ?

Pharmacy Insurance Card Front Photo

Pharmacy Insurance Card Back Photo

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. I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose
of this program is to help remind me when my/my child's immunizations are due and to keep a central record of my/my
child's immunization history.
I understand that the medical information in the NJIIS may be shared with authorized health care providers, schools,
licensed child care centers, colleges, public health agencies, health insurance companies, and others as permitted by New
Jersey Law at N.J.S.A. 26:4-131 et seq. and rules at N.J.A.C. 8:57-3.
I understand that I can get a copy of my/my child's record from my primary health care provider, my local health department,
or the New Jersey Department of Health (NJDOH). The NJDOH may be contacted at the website or telephone number
listed above.
There is no cost to participate in this program.

Signature*

VACCINE FORM

We have 2024-2025 COVID Booster shots in stock ( Pfizer and Moderna)