• COVID-19 VACCINE INFORMED CONSENT FORM

  • Patient Information

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  • We are not authorized to administer vaccines to children under 3 years old. If your child is under 3 years old, please contact their primary care physician.

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  • Please visit the pharmacy to discuss vaccine options with our pharmacist in-person.

  • IMMUNOCOMPROMISED

  • A third dose is recommended at least 28 days after the date of the second dose. You should receive the vaccine from the same manufacturer as you received for your first two doses. This dose is considered part of your primary series.

  • A third dose is recommended at least 8 weeks after the date of the second dose. You should receive the vaccine from the same manufacturer as you received for your first two doses as part of your primary series.

  • Please contact the pharmacy to review vaccine eligibility.

  • UPDATED BOOSTER

  • An updated booster dose is recommended at least 2 months after the date of your last dose. Your last dose can be part of the primary series or a previously authorized booster dose.

  • The third dose of your primary series will be the bivalent vaccine. No booster dose is approved at this time.

  • You are not eligible for a bivalent booster vaccine at this time.

  • We do not have that vaccine available at this time.
  • You are not eligible for this COVID-19 vaccine.

  • Screening Questions

    Please select the correct option below.
  • Pfizer (12+) VIS

    Pfizer (5-11) EUA

    Pfizer (6mo-4yr) EUA

    Moderna (12+) EUA

    Moderna (6-11) EUA

    Moderna (6mo-5yr) EUA

    Janssen (18+) EUA 

    Novavax (12+) EUA 

     

    Notice of Privacy Practices

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