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  • COVID-19 MODERNA VACCINE REGISTRATION AND CONSENT FORM

  • 18 years of age and older are elegible to receive this vaccine.
    Every patient will be requested an ID before vaccination.
      If you have any questions, please call us at (305) 665 4411

    IMPORTANT:
    Inmunocompromise patients are recommended a full 3rd dose 28th days after the 2nd dose

  • For more information about the CDC recommendations for immunocompromised patients, please visit:  

    https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/immuno.html

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  • Vaccine Appointment:

  • Personal Information:

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  • Immunization Screaning Questionnaire:

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  • Insurance Information:

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  • Signatures:

    I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I will be provided as an attachment with this Consent and Release. 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 and Release.

  • HIPAA DISCLOSURE

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

    I hereby voluntarily authorize the disclosure of my protected health information, including any vaccination records, provided by Marco Drugs & Compounding pharmacy to:

    Me via email, even though email is not a completely secure means of communication.
    Me via SMS, even though SMS is not a completely secure means of communication.
    The Florida Health Department and the Center for Disease Control and Prevention.

    I also understand and agree to the following:

    I may refuse to provide this authorization.
    I may revoke this authorization at any time in writing.
    I have a right to request and receive a copy of this authorization.
    This authorization is effective immediately upon signing this form.

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  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. 

  • YOU ARE CURRENTLY NOT ELEGIBLE TO GET A 3RD DOSE OF THE MODERNA COVID VACCINE

     

    3rd dose is recommended 28 days after
    the 2nd dose for immunocompromised patients

  • YOU ARE CURRENTLY NOT ELEGIBLE TO GET A BOOSTER OF THE MODERNA COVID VACCINE

     

    Booster shot is recommended 5 months after
    the 2nd dose for elegible patients

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