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Moderna 1st shot COVID-19 Immunization Scheduling and Questionnaire
Are looking to get vaccinated with Moderna's mRNA vaccine? This is a 2-shot series for patients 18 year old or older, available Tuesday and Friday only.
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Yes
No
This form is for Moderna Vaccinations ONLY. This shot is for all Minnesotans 18 YEARS OR OLDER. This is a two-shot series, available Tuesday and Friday only. We will schedule your follow up appointment 4 weeks later right before we vaccinate you. If you are interested in the Johnson & Johnson single dose vaccine please go to www.iversoncornerdrug.com and click the J & J vaccine button.
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Your Information
Name
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First Name
Last Name
Date of Birth
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/
Month
/
Day
Year
Gender
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Male
Female
Other
Phone Number
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Email
example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Health Questionnaire
Have you ever received a dose of COVID-19 vaccine?
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Yes
No
Which vaccine product did you receive?
Moderna
Pfizer
Other
Have you ever had an allergic reaction to:
This would include a severe allergic reaction (e.g., anaphylaxis) that required treatment with epinephrine or EpiPen or that caused you to go the hospital. It would also include an allergic reaction that occurred within 4 hours that cause hives, swelling or respiratory distress including wheezing.
Polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures
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Yes
No
Polysorbate
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Yes
No
A previous dose of COVID-19 vaccine
Yes
No
Any other vaccine or injectable medication?
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Yes
No
Have you ever had a severe allergic reaction (e.g., anaphylaxis)? This would include food, pet, environmental or oral medication allergies.
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Yes
No
Please describe previous allergic reactions
Have you received any vaccines in the last 14 days? Or are you planning to receive any vaccines (besides COVID) in the next month?
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Yes
No
Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
Yes
No
In the past 90 days, have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19?
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Yes
No
Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
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Yes
No
Do you have a bleeding disorder or are you taking a blood thinner?
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Yes
No
Are you pregnant or breastfeeding?
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Yes
No
I don't know
N/A
Please call Iverson Corner Drug at 218-444-3000 or your healthcare provider. If you are seeing this message, there is a problem that needs to be addressed before we can vaccinate you. Please do NOT continue past this point, the system will not allow you to schedule an appointment.
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Insurance Information
The cost of the vaccine will either be covered by your insurance or the federal government. Please provide the necessary information to make sure the vaccine is covered for you.
Do you fill prescriptions at Iverson Corner Drug?
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Yes
No
Do you have health insurance?
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Yes
No
The federal government is covering the cost of the vaccine for patients without insurance. We will need your social security number or driver's license.
Do you have Medicare?
Yes
No
What is your Medicare A/B number? Found on the red, white and blue Medicare card - it's a mix of numbers and letters
Please enter information from your insurance card
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Schedule an Appointment
First Dose Immunization Schedule
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Appt Date
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Month
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Day
Year
Date
Reminder Date
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Month
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Day
Year
Date
It's important to receive your second dose 28 days after your 1st dose. Based on your appointment date and time, will you be able to return to Iverson in 28 days for your second dose?
Yes
No
If you have reached this section WITHOUT scheduling an appointment above, we do NOT have you in our system! If you HAVE scheduled a time slot, we'll see you then! Please feel free to add any additional questions or comments:
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