Cornerstone MODERNA COVID-19 Vaccine Booster Appointment & Consent Form

****NEW GUIDELINES ****

****AVAILABLE TO ALL INDIVIDUALS AGE 18 AND OVER****

CDC’s recommendations now allow for a mix and match for vaccine type for booster shots.
Heterologous dosing (mix and match) may be considered for the booster dose only.
Patients are allowed to self-attest to needing a booster vaccine.

** IF YOU NEED TO SCHEDULE A PRIMARY SERIES OF COVID-19 VACCINE (1ST/2ND or BOTH) PLEASE CALL OUR PHARMACY @ 518-297-3784 **

Select an appointment time*

IN ORDER TO RECEIVE THE MODERNA BIVALENT COVID BOOSTER SHOT YOU MUST:

*BRING YOUR COVID VACCINATION CARD TO YOUR APPOINTMENT (If your card is full, an additional (new) card will be provided

*ATTEST TO ONE OF THE FOLLOWING STATEMENTS*

I am 18 years of age or older and have completed my primary 2 shot series (or up to 4 shots if received any boosters) of either Pfizer/Biontech or Moderna and it has been at least 2 months since my last doseI am 18 years of age or older and I am moderately to severely immunocompromised who received an additional dose following a Janssen series (second dose) and it has been at least 2 months since my last dose

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.

Vaccine Recipient Name*

First Name Middle Name Last Name

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code

Ethnicity*

Date of Birth*

Race*

Gender at birth*

Vaccine Recipient Phone Number*

Vaccine Recipient Email*

example@example.com

Mother's Maiden Name*

Required for proper vaccine documentation

Primary Care Provider Name*

Emergency Contact Name*

Relationship to Emergency Contact*

Phone Number of Emergency Contact*

Name of Insurance*

Insurance Cardholder ID #*

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine ?
3a. Have you ever had an allergic reaction to acomponent of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
3b. Have you ever had an allergic reaction* (see definition after question #5) to Polysorbate?
3c. Have you ever had an allergic reaction*(see definition after question #5) to a previous dose of COVID-19 Vaccine?
*4. Have you ever had an allergic reaction (see definition after question #5) to another vaccine (other than COVID-19 vaccine) or an injectable medication?**
*5. Have you ever had a severe allergic reaction see definition below (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication?** This would include food, pet, environmental, or oral medication allergies. * Allergic Reaction Defined: This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?

COVID-19 Vaccine Manufacturer for the first dose received (do not complete if you selected "no" to #2 above.)

Required if you selected "Yes" to #2

Date of first dose (do not complete if you selected "no" to #2 above.)

Required if you selected "Yes" to #2

COVID-19 Vaccine Manufacturer for the second dose received (do not complete if you selected "no" to #2 above.)

Required if you selected "Yes" to #2

Consent (check each box below after reading and prior to signing the form)*

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet), a copy of which I was provided with this Consent Form (link below). 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 Form.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.*

	Check one
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the 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 benefit plan.

View the Moderna Emergency Use Authorization (EUA) Fact Sheet

Please Scan the QR Code Below for Information on VSafe or click the link below

V-Safe after vaccination health tracker information

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Clear

TYPING IN MY NAME ACTS AS A DIGITAL SIGNATURE FOR CERTIFYING THAT I REVIEWED THE EUA AND V-SAFE LITERATURE*

First Name Last Name

Date Signed

Date

COVID-19 Vaccine Booster Consent Form