** You must be 18yrs and over for Moderna vaccine.
** If you are already vaccinated with either "Pfizer" or "Janssen" COVID-19 vaccine, please STOP and EXIT this form. This is for Moderna COVID-19 Vaccine only.
** Please bring your original Insurance card and Driver's License/ID with you.**
I have read, or have had read, or have had explained to me, the information in the Vaccine Information Statements for the vaccines indicated. I have had the chance to ask questions that were answered to my satisfaction. I believe that I understand the benefits and risks of the vaccines requested and have received a copy of a current FACT SHEET FOR RECIPIENTS AND CAREGIVERS EMERGENCY USE AUTHORIZATION (EUA) OF THE MODERNA COVID-19 VACCINE TO PREVENT CORONAVIRUS DISEASE 2019 (COVID-19) IN INDIVIDUALS 18 YEARS OF AGE AND OLDER. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless PharmRx Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this PharmRx Pharmacy to administer the vaccine(s).
I authorize PharmRx Pharmacy to bill either my insurance or HRSA (if no insurance) for the administration fee of the vaccine. I authorize the release of any medical or other information necessary to process this claim.
I agree to stay near the vaccination location for 15 minutes after getting vaccinated before leaving. Those with previous anaphylactic reactions should stay for 30 minutes.
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.
** Do not fill anything beyond this.