McCook's Pharmacy
23630 US Hwy 80 East Statesboro GA 30461 Phone 912-764-2223
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Are you a Georgia resident or do you work in the state of Georgia?
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Are you allergic to SM-102PEG200?
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Have you ever had a serious allergic reaction to any other vaccine or injectable?
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Do you have Covid or are you recovering from Covid?
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Have you had any other immunizations within the last 14 days?
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Do you have a moderate or severe illness today?
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Have you received passive antibody therapy withing the last 90 days?
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Do you consent to wait 15 minutes after being immunized for observation?
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For Pharmacy use Only: Vaccine: Covid, Today's Date ________________, Mfg: Moderna; Lot #______________________; Exp Date_________________ ;Dose 0.5mg ; Injection Site: Left Arm or Right Arm Administered by ________________________
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