My Pharmacy & Optical COVID-19 Vaccine Registration **Moderna Only**

This is my first, second, or third dose of the Moderna Vaccine: *

First Dose Second Dose 1st Booster 2nd Booster *see eligibility under FAQ's on website

Have you confirmed that you are eligible to receive the above dose based upon age and timeline requirements from your last dose?

Yes No

Appointment *

Salutation

First Name *

Middle Name

Last Name *

Date of Birth *

Date

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Email (must be unique to each individual) *

example@example.com

By completing this field you are attesting that you/patient is eligible to receive the Moderna vaccine. *

I am over the age of 16 or am the legal parent or gaurdian and want the MODERNA vaccine.

Please review and check ALL the boxes below *

Please bring your ID, insurance card, and vaccine card (if applicable) with you to your appointment. If you are uninsured please communicate this to our staff. Please arrive as close to your appointment time as possible to prevent traffic congestion. We ask that you do not get into line until 5 minutes before your appointment time to prevent traffic concerns. COVID vaccinations will be given outside at the back of our pharmacy under the tent and the entrance to COVID vaccination line will be the entrance off St. Peters Church Rd. Anyone arriving into the parking lot from HWY 378 will be required to exit and reenter from St. Peters Church Rd. Please allow 30 minutes upon arrival. You will be required to remain on site for 15 minutes for observation. Additional instructions will be provided upon arrival.

Please review the following:

Moderna EUA Fact Sheet - Vaccine Recipient Fact Sheet | EUA | Moderna COVID-19 Vaccine (modernatx.com)

V-Safe Registration - Get vaccinated. Get your smartphone. Get started with v-safe. (cdc.gov)

Please make sure you review the "Moderna EUA Fact Sheet" and "V-Safe Registration" above. *

I attest that I have downloaded and reviewed "Moderna EUA Fact Sheet" and "V-Safe Registration" above.

Please download and print out the form below from the CDC and Moderna.

https://www.cdc.gov/vaccines/covid-19/downloads/pre-vaccination-screening-form.pdf

Please agree to the following *

I have downloaded and printed out page 1 of the form from the CDC and Moderna link above. I will fill this form out and bring it to my appointment.

**MODERNA Vaccine Only Schedule**

MODERNA Vaccine Only Schedule