Moderna (bivalent) booster COVID-19 Immunization Scheduling Form
Initial (1st) Moderna bivalent boosters are approved for patients age 6 and older. It must be at least 2 months since last COVID-19 vaccine
Some patients now qualify for a 2nd bivalent booster including:
Patients age 65 and older who last received a COVID vaccine at least
4 months prior
Patients with immunocompromising conditions who last received a COVID vaccine at least
2 months prior
. See this
link
for a list of qualifying conditions
Bring your ID, insurance cards (if you have them) and COVID vaccine card to appointment
It does not matter which brand of COVID-19 vaccine you received previously as the CDC/FDA has approved "mixing and matching" of COVID-19 vaccines. Donlon Pharmacy is not offering the Pfizer bivalent booster at this time. If you have questions please call (563) 382-3929 and speak to a pharmacist.
Please indicate the last date you received a COVID-19 vaccine.
*
-
Month
-
Day
Year
Date
COVID-19 Vaccination Appointment
Please keep your appointment or call the pharmacy if you need to cancel or change it.
Please select an available appointment (date and time) to receive your COVID-19 vaccine.
*
Patient Information
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Patient Phone Number
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race/Ethnicity:
Caucasian
African American
Hispanic
Asian
American Indian
Pacific Islander
Other
Please select the preferred administration site to receive your COVID vaccine.
*
Left Arm
Right Arm
Submit
Should be Empty: