COVID-19 Moderna Vaccine or Booster Appointment Form for Tuesday 7/19/22
We have the Moderna COVID-19 Vaccine Available for 1st dose, 2nd dose, 1st booster, and 2nd booster. The 2nd booster shot is only available to people 50 and older or are severely immunocompromised.
You MUST bring your vaccine card to your booster shot appointment (unless this is your first dose), your drivers license or ID, and your insurance card(s). PRIMARY SERIES COVID-19 VACCINE Moderna Age Group:18+ years. Number of Doses to Complete Primary Series and Timing: 3 doses. 2nd dose given 4 weeks (28 days) after 1st dose. 3rd dose given at least 4 weeks (28 days) after 2nd dose. Booster and Timing: 1 booster Given at least 3 months after 3rd dose.
Who Is Moderately or Severely Immunocompromised?
Many conditions and treatments can cause a person to be immunocompromised (having a weakened immune system). People are considered to be moderately or severely immunocompromised if they have: Been receiving active cancer treatment for tumors or cancers of the blood, Received an organ transplant and are taking medicine to suppress the immune system, Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system, Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)Advanced or untreated HIV infection, Active treatment with high-dose corticosteroids or other drugs that may suppress their immune response. Talk to your healthcare provider about COVID-19 vaccination and your medical condition. People Who Were Vaccinated Outside of the United States, People who are moderately or severely immunocompromised and who received COVID-19 vaccines not available in the United States should either complete or restart the recommended COVID-19 vaccine series, including a booster dose, in the United States. For more information, talk to your healthcare provider, or see the COVID-19 Interim Clinical Considerations.
Please choose which dose you are requesting
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1st dose
2nd dose
1st booster
2nd booster
Appointment
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Vaccine Recipient Name
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First Name
Last Name
Are you
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18-64
65-74
75 or older
Vaccine Recipient Date of Birth
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-
Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Email ( put N/A if you don't have one)
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example@example.com
Preferred Language
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Ethnicity
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Hispanic
non Hispanic
decline
Race
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Native American or Alaskan
African American or Black
White
Asian
Native Hawaiian or Pacific Islander
Other or multi-racial
Decline
Sex assigned at birth
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male
female
other
Marital status
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single
married
legally separated
divorced
civil union
widowed
life partner
INSURANCE
PLEASE FILL THIS OUT AS THOUGHOUGHLY AS POSSIBLE
Insurance
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Private
Medicaid
Medicare D
Medicare B (red white and blue card)
Uninsured
Name of Your Primary Insurance Company (put UNISURED if not insured)
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If Private, Medicaid, or Medicare Part D please fill out below:
Rx Bin: (put N/A if not applicable)
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ID #: (put N/A if not applicable)
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Cardholder Status: (put N/A if not applicable)
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Primary
Spouse
Child
Rx Group # (put N/A if not applicable)
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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)
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Primary Care Physician: Name, Address, Phone Number
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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.
Signature
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