• COVID-19 VACCINE INFORMED CONSENT FORM

  • Patient Information

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  • A booster dose is recommended for you if it has been at least two (2) months since your first dose. The CDC recommends receiving your booster dose from the same manufacturer as your primary dose(s), but you may opt to receive a dose from a different manufacturer.
  • If you received Janssen for your original dose as well as your first booster dose, you are eligible to receive a second booster dose of Moderna or Pfizer at least 4 months after your first booster dose.
  • IMMUNOCOMPROMISED

  • A 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.
  • A booster dose is recommended at least 3 months after the date of your last dose. Depending on your age, you may choose which manufacturer’s vaccine you would like to receive for the booster dose. Pfizer is approved for those 12 or older; Moderna is approved for those 18 or older.
  • You are eligible to receive a second booster dose at least 4 months after the date of your last dose. Depending on your age, you may choose which manufacturer’s vaccine you would like to receive for the booster dose. Pfizer is approved for those 12 or older; Moderna is approved for those 18 or older.
  • NOT IMMUNOCOMPROMISED

  • A booster dose is recommended at least 5 months after the date of your last dose. Depending on your age, you may choose which manufacturer’s vaccine you would like to receive for the booster dose. Pfizer is approved for those 12 or older; Moderna and Janssen are approved for those 18 or older.
  • You are eligible to receive a second booster dose at least 4 months after the date of your last dose.
  • You do not qualify for an additional dose at this time.
  • We do not have that vaccine available at this time.
  • You are not eligible for this manufacturer's vaccine.
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  • Pfizer (12+) VIS | Pfizer (5-11) EUA | Moderna EUA | Janssen EUA Notice of Privacy Practices

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  • After submitting, you will be redirected to schedule your appointment. Please make sure to confirm your appointment so we save your spot on our schedule. If you are scheduling for COVID-19 and another vaccine, please only make the COVID-19 appointment. If there are no appointments available for the vaccine you need, please check back.
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