• COVID-19 VACCINE INFORMED CONSENT FORM

  • Patient Information

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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 as 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.
  • A booster dose of Pfizer Pediatric (5-11) is recommended at least 3 months after the date of your last dose.
  • MONOVALENT BOOSTER

  • A booster dose of Pfizer Pediatric (5-11) is recommended at least 5 months after the date of your last dose.
  • 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.
  • REASONS TO STOP FORM

  • 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.
  • You are eligible for an updated booster dose, which we do not have at this time. Please check back next week for updated information.
  • 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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  • 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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