COVID-19 Moderna Booster Appointment Form for December 20, 21, 27, and 28
You MUST have had 2 doses of Moderna or Pfizer or 1 dose of J&J before signing up for a booster shot.
You MUST bring your vaccine card to your booster shot appointment, your drivers license or ID, and your insurance card(s). The use of a single booster dose of the Moderna COVID-19 Vaccine may be administered at least 6 months after completion of the primary series. If you need a first or second dose of Moderna, please CALL us to schedule, as we need to note the full dose 518-589-9500.
75 or older
Vaccine Recipient Name
Vaccine Recipient Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Email ( put N/A if you don't have one)
Native American or Alaskan
African American or Black
Native Hawaiian or Pacific Islander
Other or multi-racial
Sex assigned at birth
PLEASE FILL THIS OUT AS THOUGHOUGHLY AS POSSIBLE
Medicare B (red white and blue card)
Name of Your Primary Insurance Company (put UNISURED if not insured)
If Private, Medicaid, or Medicare Part D please fill out below:
Rx Bin: (put N/A if not applicable)
ID #: (put N/A if not applicable)
Cardholder Status: (put N/A if not applicable)
Rx Group # (put N/A if not applicable)
If Medicare Part B (Red/White/Blue card) please provide card number below:
Medicare Part B (Red/White/Blue card) number: (put N/A if not applicable)
Primary Care Physician: Name, Address, Phone Number
I will read, or have explained to me, the information sheet about the COVID-19 booster on the day of my appointment. I understand I will have a chance to ask questions to be answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described. I request that the COVID-19 booster vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I authorize release of all information needed(including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform