COVID-19 Moderna Vaccine or Booster Appointment Form for Tuesday 10/18/22
You MUST bring your vaccine card to your booster shot appointment (unless this is your first dose), your drivers license or ID, and your insurance card(s).
We have the Moderna COVID-19 MONOVALENT Vaccine Available for 1st dose & 2nd dose
We have the Moderna COVID-19 BIVALENT Vaccine Available for all boosters.
Moderna COVID-19 Vaccine, Bivalent has received EUA from FDA to provide either: a single booster dose to individuals 18 years of age and older at least 2 months after completion of primary vaccination series with any authorized or approved monovalent COVID-19 vaccine; or a single booster dose to individuals 18 years of age and older at least 2 months after receipt of the most recent booster dose with any authorized or approved monovalent COVID-19 vaccine.
Please choose which vaccine you are requesting.
1st dose (MONOVALENT)
2nd dose (MONOVALENT)
Vaccine Recipient Name
75 or older
Vaccine Recipient Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Email (put firstname.lastname@example.org if you don't have one)
Native American or Alaskan
African American or Black
Native Hawaiian or Pacific Islander
Other or multi-racial
Sex assigned at birth
PLEASE FILL THIS OUT AS THOUGHOUGHLY AS POSSIBLE
Medicare B (red white and blue card)
Name of Your Primary Insurance Company (put UNISURED if not insured)
If Private, Medicaid, or Medicare Part D please fill out below:
Rx Bin: (put N/A if not applicable)
ID #: (put N/A if not applicable)
Cardholder Status: (put N/A if not applicable)
Rx Group # (put N/A if not applicable)
If Medicare Part B (Red/White/Blue card) please provide card number below:
Medicare Part B (Red/White/Blue card) number: (put N/A if not applicable)
Primary Care Physician: Name, Address, Phone Number, put N/A if not applicable
I will read, or have explained to me, the information sheet about the COVID-19 vaccine or booster on the day of my appointment. I understand I will have a chance to ask questions to be answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described. I request that the COVID-19 booster vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.
Should be Empty: