Moderna COVID-19 Vacc Appt Scheduling and Consent Form

COVID-19 Vaccine Consent Form
1. Are you feeling sick today?*

YesNo
2. Please select COVID Vaccine doses you have already received, if any:

Moderna - 1st DoseModerna - 2nd DoseModerna - 3rd Dose/ 1st Booster DoseModerna - 2nd Booster DoseOtherNone
COVID Doses Received
If you have received one or more doses of COVID-19 vaccine, please bring your COVID-19 Vaccination Record Card to your scheduled appointment
You indicated you have received both a first and second vaccine along with both the first and second booster doses. No further doses are currently indicated. If this is correct, please click here to return to our website. Further information will be provided here as it is received. If this is incorrect, please click "back" below to return to the previous page and make the correction.

Vaccine Recipient Name*

First NameLast Name
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code
Is mailing address the same as physical address?*

YesNo
Vaccine Recipient Mailing Address

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code
Date of Birth*

MonthDayYear
Gender at birth*
Race*
Ethnicity*
Vaccine Recipient Phone Number*
Vaccine Recipient Cell Phone Number
Vaccine Recipient Email Address*
Required in order to send you a confirmation email.
Do we have permission to send you text and email reminders and pharmacy information?

YesNo
Type a question
Mother's Maiden Name*
Required for proper vaccine documentation
Primary Care Provider Name:
Emergency Contact Name*
Relationship to Vaccine Recipient*
Phone Number of Emergency Contact*

Consent (check EACH box below after reading and prior to signing the form)

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet is available again after clicking submit), a copy of which I was provided prior to completion of this Consent Form. 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 Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.

The vaccine is available to anyone no matter if insured or uninsured. Please check ONLY ONE of the following.*

	Check ONLY ONE
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.

For UNINSURED patients, please select at least one of the following that you will bring with you to your appointment.

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance
Social Security Number or State ID#
State of Issuance (If applicable)
Optional:

Commercial Insurance:

Enter the following numbers from your Prescription Insurance Card in order to make your vaccine experience quicker and smoother.

Medicare:

Enter your medicare ID number found on your Red, White, and Blue medicare card in the ID field below.

Oklahoma Medicaid:

Enter your medicaid ID number in the ID field below.

Please bring your card with you for verification.
BIN:
PCN:
Group:
ID:

In the event that vaccine allocation does not allow for us to accomodate recipients as originally scheduled, you will be contacted to reschedule your appointment.
Select an appointment date and time*
Please confirm your appointment time here:

This will help us ensure appropriate social distancing in the pharmacy. Please double check to make sure the time entered here is the same as the time chosen above.
Date*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option

Name of Person to Receive Vaccine & EUA/VIS (or name of Parent/Guardian if Patient is < 18 years old):
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Clear
Billed 1
Billed 2
Billed 3
OSIIS 1
OSIIS 2
OSIIS 3
JF 1
JF 2
JF 3
Second Dose
Date Signed

MonthDayYear
Date
Should be Empty:

COVID-19 Vaccine Consent Form