New York State Department of Health Bureau of Immunization COVID-19 Immunization Screening and Consent Form
Please fill out this Immunization Screening and Consent Form for your dose of the Moderna Covid vaccine.
Please review the Emergency Use Authorization (EUA) of the Moderna Covid-19 Vaccine.
Please review the V-Safe after vaccination health tracker. This helps the recipient report adverse effects after vaccination when they leave the facility.
DIGITAL SIGNATURE WILL BE REQUIRED BELOW THAT THE PATIENT HAS REVIEWED THE EUA AND V-SAFE HEALTH TRACKER.