• Influenza // Moderna Bivalent Covid Booster Immunization Consent

    Vaccine administered by Cornerstone Drug & Gift
  • "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."

  • - If you ONLY want the Influenza (Flu) Shot then ONLY check Influenza

    - If you ONLY want the Moderna Bivalent Booster Shot then ONLY choose the Moderna Bivalent Booster

    - ONLY select BOTH boxes if you wish to receive BOTH vaccinations during your appointment

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    Pick a Date
  • ** 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

  • 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

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