Moderna Bivalent Booster Doses

BOOSTER DOSES

of the Moderna Brand

BiValent COVID-19 Vaccine In Store

IMPORTANT:

This form is ONLY for people who qualify for a booster dose

of the COVID-19 vaccine.

YOU MUST BE 18 YEARS OR OLDER TO RECEIVE THE VACCINE BOOSTER.

You can receive your Booster doses at Fairmount Pharmacy if you received your other doses somewhere else. Should you have any questions, simply telephone our staff and we will assist you with registering your booster shot with us!

THE DATE FOR YOUR BOOSTER DOSE MUST BE AT LEAST 2 MONTHS AFTER COMPLETION OF PRIMARY VACCINATION OR RECEIPT OF THE MOST RECENT BOOSTER DOSE WITH ANY AUTHORIZED OR APPROVED MONOVALENT COVID-19 VACCINE.

You must bring your CDC vaccination record card with you.

Completing this form will allow you to schedule a BOOSTER DOSE appointment to receive the MODERNA BivalentCOVID-19 vaccine at

Fairmount Pharmacy

1900 Green Street

Philadelphia, PA, 19130

PLEASE BRING YOUR INSURANCE CARD AND ID.

PLEASE WEAR SHORT SLEEVES FOR EASE OF ACCESS TO INJECTION SITE.

You must bring your CDC Vaccination Record Card with you.

We look forward to seeing you!

I acknowledge that I qualify for the Moderna BiValent COVID-19 vaccine to be administered at Fairmount Pharmacy. (Must be at least 3 months since a confirmed COVID-19 infection or 2 months after your most recent dose). Please refer to your CDC Vaccination Record Card to be sure appointment is at least 2 months after your most recent dose).*

Yes

Date of your MOST RECENT dose (found on your CDC Vaccination Record Card). BOOSTER DOSES ARE FOR PEOPLE 18 YEARS OF AGE AND OLDER ONLY. THIS DATE MUST BE AT LEAST 2 MONTHS PRIOR TO DATE OF REQUESTED IN ORDER TO SCHEDULE YOUR BOOSTER DOSE.

Date

Appointment*

Vaccine Recipient First Name*

Vaccine Recipient Last Name*

Gender*

Date of Birth*

Date

Social Security Number: PLEASE NOTE-THIS FORM IS HIPAA COMPLIANT AND ENCRYPTED FOR YOUR SECURITY. Fairmount Pharmacy uses your SSN to determine insurance coverage ONLY and does not share your information. Should you wish not to provide, please be sure to bring in your current insurance information at the time of your appointment. Please know there is NO cost for the vaccine, but pharmacies can bill for administration of the vaccine.

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

In which arm would you like to receive your COVID-19 vaccine?*

Left ArmRight Arm

Vaccine Recipient Phone Number*

Cell phone preferred.

E-Mail Address

Race*

Ethnicity*

Emergency Contact Name*

Relationship to Emergency Contact*

Phone Number of Emergency Contact*

Please enter a valid phone number.

If patient is a minor, please complete the following.

Parent/Guardian First NameParent/Guardian Last Name

COVID-19 Vaccine Screening Questions*

	Yes	No
1. Are you feeling sick today? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
2. Have you received a previous DOSE of COVID-19 Vaccine?
3. Have you ever had an allergic reaction to: a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications such as laxatives and preparations for colonoscopy procedures -or- Polysorbate -or- a previous dose of COVID-19 vaccine NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine or an injectable medication? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
5. Have you ever had a severe allergic reaction (e.g. anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies. NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
6. Have you received any vaccine in the last 14 days? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
7. Have you recently had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
10. Do you have a bleeding disorder or are you taking a blood thinner? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.
11. Are you pregnant or breastfeeding? NOTE: If you answer YES to this question, do NOT schedule your appointment until you have received clearance from your medical professional.

Consent (check each box below after reading and prior to signing the form*

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer Fact Sheet is available herein - https://www.fda.gov/media/144414/download. I request the vaccine to be given to me.
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.
I understand that at this time, the COVID-19 vaccine Booster appointment will be scheduled at least 2 months from the date I receive my most recent dose or 3 months after a positive COVID-19 infection.
I understand that I will be receiving the vaccination at no cost to me.

PLEASE RECORD THE DATE AND TIME OF YOUR APPOINTMENT PRIOR TO SUBMITTING THIS FORM!

YOUR CONFIRMATION WILL NOT HAVE THIS INFORMATION.

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Clear

Date Signed*

Date