CORNERSTONE ONLY - Influenza // Moderna Bivalent Booster Immunization Consent Form

"It is 100% Safe to receive the Influenza vaccine as well as the Moderna Bivalent Covid Booster Vaccine at the same time. If you would like to do so please indicate when asked below. If you have recently recovered from Covid (within the past 3 months), you can still get the bivalent booster, but can also safely hold off for a few months. You can ONLY receive the Moderna Bivalent Booster Shot if it has been at least 2 months since your last covid vaccination."

Please indicate which vaccine you wish to receive (Choose all that apply) *

Influenza Moderna Bivalent Booster

Appointment *

Name *

First Name Last Name

Date of Birth *

Date

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Ethnicity *

Race *

Sex *

Mother's Maiden Name (Last Name ONLY) *

Physician's Name OR *

First Name Last Name

Practice Name

Physician or Practice Phone Number *

Physician or Practice Phone Number.

Name of Insurance *

Insurance Cardholder ID # *

1. Are you sick today? *

YES NO

2. Do you have allergies to medications, food, a vaccine component or latex? *

YES NO

3.Have you ever had a serious reaction after receiving a vaccination? *

YES NO

4. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g., diabetes), anemia, or other blood disorders? *

YES NO

5. Do you have cancer, leukemia, HIV, AIDS or any other immune system problem> *

YES NO

6. In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn's disease, or psoriasis; or have you had radiation treatments? *

YES NO

7.Have you had a seizure or brain or other nervous system problem? *

YES NO

8. During the past year, have you received a transfusion of blood or blood products or been given immune (gamma) globulin or an antiviral drug? *

YES NO

9. For Women, Are you pregnant or is there a chance you could become pregnant during the next month? *

YES NO

10. Have you received any vaccinations in the past 4 weeks? *

YES NO

** IF YOU ARE RECEIVING A MODERNA BIVALENT COVID BOOSTER SHOT IN ADDITION TO INFLUENZA, YOU MUST:

1) BRING YOUR COVID VACCINATION CARD TO YOUR APPOINTMENT (If your card is full, an additional (new) card will be provided

2) ATTEST TO ONE OF THE FOLLOWING STATEMENTS *

I am 18 years of age or older and have completed my primary 2 shot series (or up to 4 shots if received any boosters) of either Pfizer/Biontech or Moderna and it has been at least 2 months since my last dose I am 18 years of age or older and I received 1 (or 2) doses of Janssen vaccine and it has been at least 2 months since my last dose

Immunization Agreement
I understand that the pharmacy advises me to remain within the pharmacy at least 20 minutes after the injections for observation. I will notify the pharmacy of any adverse events associated with immunization. Permission is herby granted to Cornerstone Drug and Gift, Inc. to release information to my primary care provider, identified above, regarding any vaccinations received today. I agree to be vaccinated today with the following vaccine: Influenza

NYSIIS Reporting
Our Pharmacy and the New York State Department of Health want to inform you about the Statewide Immunization Information System(IIS) By law, any immunizations given to patients under the age of 19 must be reported into a secure web-based IIS and this electronicsystem is Called the New York State Immunization Information System (NYSIIS).For patients aged 19 and older, immunizations may be reported to NYSIIS with patient consent. Inclusion of adults will significantly contribute to a fully-developed, population-based database of accurate immunization records, and complete date is essential to developing statewide immunization programs intended to reduce the burden of vaccine preventable disease.

By signing below, I agree to the reporting of my vaccine administration to NYSIIS

Signature *

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Influenza // Moderna Bivalent Covid Booster Immunization Consent