COVID Immunization Consent Form
Please have your pharmacy insurance card ready when completing
Please fill out and submit this form.
This is only for the Moderna COVID-19
The administration of this vaccine may be billed to your insurance benefits. There will be no out-of-pocket cost.
Choose a payment method
My insurance is already on file at the Pharmacy
Medicare Part B
I don't have insurance coverage.
Insurance Card Information
Please input each of the following for your insurance card.
Medicare Card Information
Please input your identification number as it appears on your Medicare card.
Patient Name as written on INSURANCE CARD
Last 4 of your SSN
Date of Birth
Patient Phone Number
Street Address Line 2
State / Province
Postal / Zip Code
Fact Sheet for Vaccine Recipients and Caregivers
Please click on the link below to read the Emergency Use Authorization (EUA) of the J&J COVID-19 Vaccine and complete the acknowledgement statement after reading the document. A printed copy of this information will be available at the pharmacy upon request.
Moderna COVID-19 Vaccine EUA fact sheet
I have read the EUA fact sheet for the Moderna COVID-19 Vaccine.
Yes, I have read the information provided above.
Consent to Vaccination
I have read, or have had explained to me, the information provided in the EUA fact sheet. I have or plan to address any questions or concerns regarding the vaccine with my healthcare provider or pharmacist prior to receiving the vaccine. I understand the benefits and risks of the COVID-19 vaccine and ask that the vaccine be administered to me or the person named above for whom I and authorized to make this request. I authorize documentation of this vaccination administration be forwarded to my primary care physician and the state-wide immunization registry. I understand it is recommended to remain in the general area for 15 minutes after receiving my vaccination in case any immediate reaction occurs. I understand that if I experience any side effects, it will by my responsibility to follow up with my physician at my expense. I hereby release Central Pharmacy - Charlotte its officers, employees, and agents, the owner and/or operator of the clinic site, its officers, employees, and agents from any and all liability that might arise from this vaccination on behalf of myself, my heirs, and personal representatives.
Form completed by
Signature of Person Receiving the Immunization
Pharmacy Use Only
Do no complete the below questions
Signature of Pharmacist
Should be Empty: