Alden Pharmacy Moderna COVID-19 Vaccine and Consent Form

Do you consent to having your vaccination record shared with the New York State Immunization Registry? (You must consent to receive a vaccination) *

I consent
I agree to bring my insurance card(s) and my COVID-19 vaccination card (if I am receiving a second dose or booster dose of the COVID-19 vaccine) to my appointment *

I agree
I understand that the COVID-19 vaccine is being administered under an FDA Emergency Use Authorization order and that the vaccine is not yet FDA-approved. A copy of the EUA is available on the Alden Pharmacy website. I am consenting to receive this vaccine. *

I consent
I understand that once I hit the Submit button I will receive a confirmation screen to confirm my appointment. If I do not receive a confirmation screen, then the appointment time I selected is full and I would need to start over selecting a new appointment time. *

I understand
Should be Empty:

Alden Pharmacy Vaccine Form