ATTN: THIS IS FOR THE MODERNA (12yrs+) COVID-19 VACCINE. WE DO NOT CURRENTLY HAVE VACCINE FOR UNDER 12 YEARS OLD. WE ALSO DO NOT CURRENTLY HAVE ANY PFIZER VACCINE. PLEASE CHECK BACK AS WE WILL PLAN TO HAVE THOSE AVAILABLE IN THE COMING WEEKS
Section I. Personal Information
Current protocols require your last COVID-19 vaccination to have been 2 months or more prior to receiving the updated vaccine. You indicated that time frame has not been met thus you are currently unavailable to receive the vaccine. Please call with any questions.
Section IV. Signatures
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), https://www.cdc.gov/vaccines/covid-19/eui/index.html , Moderna (Spikevax) patient information sheet, Pfizer (comirnaty) patient information, a copy of which I was provided with this Consent and Release. 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 and Release.
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.