• COVID-19 VACCINE CONSENT FORM

  • Vaccination Status

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  • COVID-19 VACCINATION ATTESTATION FOR ADDITIONAL DOSE

    This attestation form is used to verify your eligibility to receive an additional dose of COVID-19 vaccine and is currently only for those who received Pfizer or Moderna two-dose primary series.
  • For moderately to severly immonocompromised, third dose is recommended at least 28 days after the date of the second dose. You will receive the vaccine from the same manufacturer as you received for your primary series. 

  • If you are 18 years or older, a booster dose is recommended at least 6 months after the date of the second dose.You may choose which manufacturer’s vaccine you would like to receive for the booster dose.

  • By signing below, I attest that I meet one or more of the criteria listed above.
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  • Screening Questionnaire

  • Insurance Information

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  • Pfizer Vaccine Information Sheet (VIS)

    Pharmacy Notice of Privacy Practices

  • Moderna Emergency Use Authorization (EUA)

    Pharmacy Notice of Privacy Practices

  • Janssen/Johnson and Johnson Emergency Use Authorization (EUA)

    Pharmacy Notice of Privacy Practices

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