• COVID Vaccine Consent Form

  • Bivalent Booster shots are available 2 months from your previous Covid-19 vaccination.

    Booster shots are now on a walk-in basis, Monday - Friday, 10-4:30pm.

  • Section I. Personal Information

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  • Section II. Questionnaire for Immunization

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  • **Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements; we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.** 

  • Section IV. Signature

    I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf) a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.

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  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

  • Imported Information

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