Moderna COVID-19 Vaccine Consent Form
Select an appointment time. Appointments will be held at Brehme Drug, 220 East Main Street, Manchester IA 52057.
Please re-enter the appointment date and time selected above.
Vaccine Recipient Name
Date of Birth
(Vaccine recipient must be 18 years of age or older to receive the Moderna Bivalent vaccine)
Sex at Birth
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
Primary Care Provider Name
Mother's Maiden Name
Emergency Contact Name
Emergency Contact Relation
Emergency Contact Phone Number
Please enter a valid phone number.
Select the vaccine receiving:
Moderna (Spikevax) 2023-24 Formula
Please select other vaccine(s) you would like at the same appointment as the COVID vaccine:
Are you feeling sick today?
Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG) or polysorbate or a previous dose of COVID-19 vaccine?
Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
(This would include a severe allergic reaction [eg. anaphylaxis] that required treatment with epinephrine or EpiPen(R) or that caused you to go to the hospital. It would also include an allergic reaction that caused hives, swelling, or respiratory distress, including wheezing.)
Have you ever had a severe allergic reaction (eg. anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication?
This would include food, pet, venom, environmental, or oral medication allergies.
Do you have a bleeding disorder or are you taking a blood thinner?
Do you have a history of myocarditis or pericarditis?
Have you been diagnosed with Multisystem Inflammatory Syndrome?
Do you have a history of heparin-induced thrombocytopenia (HIT) or thrombosis with thrombocytopenia syndrome (TTS)?
Do you have a history of Guillain-Barre Syndrome (GBS)?
Consent (check each box below after reading)
Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this Consent Form. I have had a change to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, for whom I represent that I am authorized to sign this Consent Form.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
If INSURED, check this box attesting to bringing in your prescription & medical insurance cards. By selecting, you are also authorizing the pharmacy to bill your insurance on your behalf.
If UNINSURED, you must check this box to attest that the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.
Vaccines may be billed to your pharmacy benefits. Please contact your plan directly if you have questions regarding insurance coverage of vaccines.
Chose a payment method
My insurance is already on file
Pay Out of Pocket (no insurance)
Insurance Card Information
Please input each of the following from your commercial / Medicare Part D insurance card.
Take photo of your Medicare A/B Card or prescription insurance card (if you do not have Medicare).
Medicare A/B Number
Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Should be Empty: