Section IV. Signatures
In an attempt to reduce paper waste, all legally required documents must be downloaded here. Very limited copies will be available on clinic day.
Click this to download the Emergency Use Authorization for the BIVALENT booster Moderna Vaccine.
Click this to download the Notice of Privacy Practices
Click this to download the CDC vSafe app flyer
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this registration.
I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
I certify that I have received, read, and understand the Emergency Use Authorization.
I certify that I have received the Notice of Privacy Practices.
I certify that I have received the CDC vSafe informational flyer.
I certify I am at least 18 years of age. (ID will be required)
I understand this appointment is for the Moderna vaccine.
Please type your full name in the box below. You agree your typed full name represents your electronic signature is the legal equivalent of your manual signature on this form.