• COVID-19 Moderna Booster Appointment Form for January 18th

  • 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.
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  • INSURANCE

    PLEASE FILL THIS OUT AS THOUGHOUGHLY AS POSSIBLE
  • If Private, Medicaid, or Medicare Part D please fill out below:

  • If Medicare Part B (Red/White/Blue card) please provide card number below:

  • Consent

    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.
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