Welcome!

Please complete this form in order to register to receive the Moderna COVID-19 vaccine (Spikevax).

Moderna Brand (Spikevax)

IMPORTANT:

Feel Free to call pharmacy should you need any assistance registering. Our staff will be happy to help you!

YOU MUST BE 12 YEARS OR OLDER TO RECEIVE THIS VACCINE.

You can receive the up-to-date 2024 COVID-19 vaccine at Fairmount Pharmacy if you received your other doses somewhere else. Should you have any questions, simply telephone our staff and we will assist you with registering your shot with us!

Thank you for choosing Fairmount Pharmacy for your pharmacy's vaccination needs. We look forward to the opportunity to serve members of our community.

Completing this form will allow you to schedule a VACCINE DOSE appointment to receive the 2024 MODERNA Spikevax COVID-19 vaccine

at

Fairmount Pharmacy

1900 Green Street

Philadelphia, PA, 19130

PLEASE BRING YOUR INSURANCE CARD AND ID.

PLEASE WEAR SHORT SLEEVES FOR EASE OF ACCESS TO INJECTION SITE.

We look forward to seeing you!

Yes

Appointment*

Vaccine Recipient First Name*

Vaccine Recipient Last Name*

Gender*

Date of Birth*

Date

Social Security Number: PLEASE NOTE-THIS FORM IS HIPAA COMPLIANT AND ENCRYPTED FOR YOUR SECURITY. Fairmount Pharmacy uses your SSN to determine insurance coverage ONLY and does not share your information. Should you wish not to provide, please be sure to bring in your current insurance information at the time of your appointment. Please know there is NO cost for the vaccine, but pharmacies can bill for administration of the vaccine.

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Left ArmRight Arm

Vaccine Recipient Phone Number*

Cell phone preferred.Format: (000) 000-0000.

E-Mail Address

YESNO

Race*

Ethnicity*

Emergency Contact Name*

Relationship to Emergency Contact*

Phone Number of Emergency Contact*

Please enter a valid phone number.Format: (000) 000-0000.

If patient is a minor, please complete the following.

Parent/Guardian First NameParent/Guardian Last Name

Health Information Survey:

Rows	YES	NO
Do you have allergies or reactions to any foods, meds, vaccines, or latex? (Ex:eggs, gelatin, neomycin, thimerosol, etc.) or have you ever had a severe allergic reaction (ex:anaphylaxsis) to something? For example: a reaction for which you were treated with epinephrine (Epi-Pen) or for which you had to go yo the hospital? if yes, what are you allergic to?
Have you ever had a serious reaction after receiving a vaccination? Do you have a history of fainting, particularly with vaccines? Has any physician or any other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
Have you had a seizure or a brain or other nervous system problem or Guillain Barre Syndrome?
Do you have a history of myocarditis (inflammation of the heart muscle), pericarditis (inflammation of the lining around the heart), multisystem inflammatory syndrome (MIS-C or MIS-A), or thrombocytopenia syndrome (TTS)? Do you have a bleeding disorder or take blood thinners such as Warfarin/Coumadin?
Have you ever had a severe allergic reaction after receiving a vaccine?
Are you moderately or severely immunocompromised from a medical condition/immunosuppressive therapy, including but not limited to: active treatment for solid tumor/hematologic malignancy, solid organ/stem-cell transplant, primary immunodeficiency syndrome, advanced/untreated HIV infection, or active treatment with high dose corticosteriods/other immunosuppressive/immunomodulatory biologic agents?
Are you pregnant or do you plan on becoming pregnant in the next 30 days?

Consent (check each box below after reading and prior to signing the form*

Rows	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Moderna Fact Sheet is available herein - https://www.fda.gov/media/144638/download. I request the vaccine to be given to me.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that at this time, the COVID-19 vaccine appointment will be scheduled at least 2 months from the date I receive my most recent dose or 3 months after a positive COVID-19 infection.
I understand that I will be receiving the vaccination and there may a co-payment from my insurance that is my responsibility.

PLEASE RECORD THE DATE AND TIME OF YOUR APPOINTMENT PRIOR TO SUBMITTING THIS FORM!

YOUR CONFIRMATION WILL NOT HAVE THIS INFORMATION.

Signature of Person to Receive Vaccine & EUA/VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Date Signed*

Date

Welcome!

Link for Additional Information Regarding 2023 COVID-19 Vaccine: https://www.cdc.gov/vaccines/hcp/vis/current-vis.html