COVID-19 Moderna BIVALENT Booster Appointment Form for Tuesday 3/28/23
You MUST bring your vaccine card to your booster shot appointment, your drivers license or ID, and your insurance card(s).
We have the Moderna COVID-19 BIVALENT Vaccine Available for all boosters. Please review eligibility.
BIVALENT ELIGIBILITY
People ages 12 years and older: A 2-dose primary series and 1 bivalent mRNA booster dose (Moderna or Pfizer-BioNTech) is recommended. The primary series doses are separated by 4–8 weeks and the bivalent mRNA booster dose is administered at least 2 months after completion of the primary series (for people who have not received any booster doses), or at least 2 months after the last monovalent booster dose.
Appointment
*
Vaccine Recipient Name
*
First Name
Last Name
Are you
*
12-17* legal guardian must be present*
18-64
65-74
75 or older
Vaccine Recipient Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email (put none@gmail.com if you don't have one)
*
example@example.com
Preferred Language
*
Ethnicity
*
Hispanic
non Hispanic
decline
Race
*
Native American or Alaskan
African American or Black
White
Asian
Native Hawaiian or Pacific Islander
Other or multi-racial
Decline
Sex assigned at birth
*
male
female
other
Marital status
*
single
married
legally separated
divorced
civil union
widowed
life partner
INSURANCE
PLEASE FILL THIS OUT AS THOUGHOUGHLY AS POSSIBLE
Insurance
*
Private
Medicaid
Medicare D
Medicare B (red white and blue card)
Uninsured
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)
*
Primary
Spouse
Child
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
*
Consent
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.
Signature
*
Clear
Legal Guardian Signature (if patient under 18 yrs)
Clear
Submit
Should be Empty: