Combo COVID+/- Booster Consent Form

Please select which of the following applies to you: *

I need to receive the FIRST dose of my COVID vaccination series I need to receive the SECOND dose of my Pfizer or Moderna vaccination series I need a BOOSTER dose after completing a Pfizer or Moderna vaccination series I need a BOOSTER dose after a Janssen vaccination I am a Parent or Guardian and need to sign up my age 5 to 11 Child. I am a Parent or Guardian and need to sign up my age 5 to 11 Child for a BOOSTER I need my SECOND BOOSTER after completing a Pfizer or Moderna vaccination series
Which COVID vaccination would you like to receive for your dose? *
Date of Janssen Dose *

Month Day Year
Date
Date of First Dose *

Month Day Year
Date
First Dose *
Date of Second Dose *

Month Day Year
Date
Second Dose *
Date of Booster *

Month Day Year
Date
Booster Dose *
Sorry, You don't seem to meet the criteria.

For Moderna Boosters you must wait at least 5 months to receive a booster after your second dose.

Check back in when you qualify.
Sorry, You don't seem to meet the criteria.

For Pfizer Boosters you must wait at least 5 months to receive a booster after your second dose.

Check back in when you qualify.
Sorry, You don't seem to meet the criteria.

For Boosters after Janssen vaccinations you must wait at least 2 months to receive a booster.

Check back in when you qualify.
Sorry, You don't seem to meet the criteria.

For a 2ND Booster you must wait at least 4 months to receive a booster.

Check back in when you qualify.
Sorry, You don't seem to meet the criteria.

For the second dose of Pfizer you must wait at least 21 days from your 1st dose.

Check back in when you qualify.
Sorry, You don't seem to meet the criteria.

For the second dose of Moderna you must wait at least 28 days from your 1st dose.

Check back in when you qualify.

Booster Self-Attestation

The CDC has approved a booster dose for all three COVID-19 Vaccine Products.

Moderna

For individuals who received a Moderna COVID-19 vaccine, the following groups are eligible for a booster shot at 5 months or more after their initial series is complete:
- 18 years and older
Pfizer-BioNTech

For individuals who received a Pfizer-BioNTech COVID-19 vaccine, the following groups are eligible for a booster shot at 5 months or more after their initial series is complete:
- 5 years and older
Janssen / Johnson & Johnson

People aged ≥18 years who received a single dose Janssen primary series (1 dose) should receive a COVID-19 booster dose at least 2 months after completing the primary series.
Select the group/qualification that applies to you: *
Print Name *
Date *

Month Day Year
Date
Signature *

Clear

2nd Booster Self-Attestation

The CDC has approved a 2nd booster dose for Moderna and Pfizer COVID Vaccine Products.

Eligible if you received your first booster dose at least four months ago, and meet any ONE of the followingrequirements:

> 50 years or older

> 12 years or older and are moderately to severely immunocompromised:
- Been receiving active cancer treatment for tumors or cancers of the blood
- Received an organ transplant and are taking medicine to suppress the immune system
- Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system
- Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)
- Advanced or untreated HIV infection
- Active treatment with high-dose corticosteroids or other drugs that may suppress their immune response
2nd Booster Attestation
Select the group/qualification that applies to you: *
Print Name *
Date *

Month Day Year
Date
Signature *

Clear

	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 is available after clicking submit), a copy of which I was provided with this Consent Form. 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 understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
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.

Select Appointment Time *
Janssen Scheduler *
Date

Month Day Year
Date
Hour Minutes AM/PM Option
Should be Empty:

	Yes	No	Don't Know
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 a component 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 to Polysorbate?
3c. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. Have you ever had a severe allergic reaction (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.)
6. Have you received any vaccine in the last 28 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?
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?
12. Do you have dermal fillers?
13. Do you have a history of myocarditis or pericarditis?
14. Do you have a history of Guillain-Barre Syndrome (GBS)?
15. Have you been diagnosed with Multisystem Inflammatory Syndrome after a COVID19 infection?
16. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes) anemia or other blood disorder?