Moderna COVID-19 Vaccine Appointment Scheduler

Moderna COVID-19 Vaccine Consent Form

In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
Please Select Dose*
Would you like us to check your benefits to see if you are eligible to receive FREE OTC Covid-19 test kits and provide them to you at your scheduled appointment time?*

Yes! Please check to see if I am eligible to receive FREE OTC Covid-19 Kits.No, I do not need any OTC COVID-19 test kits at the moment
Would you like to receive your annual flu shot as well during the same visit?*

Yes! I would like to get the flu shot during the same visit. ($0 copay on most insurances, if there is a cost we will communicate this to you prior to administering)No, I would much rather wait and come back another day to get the flu shot.
Select an appointment time*
Vaccine Recipient Name*

First Name Middle Name Last Name
Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code
Cell Phone Number*
(If you do not have a cell phone, please enter your home number)
Date of Birth*

YearMonth Day
Must be at least 18 years old
Social Security Number
Required for proper vaccine documentation and proper identification
Gender at birth*
Race*
Ethnicity*
Vaccine Recipient Email*
This is important as we will make communications and send appointment confirmations via e-mail
Primary Care Provider Name
Emergency Contact Name
Relationship to Emergency Contact
Phone Number of Emergency Contact

COVID-19 Vaccine Screen Questions*

	Yes	No
1. Are you feeling sick today?
2. Have you ever received a dose of COVID-19 Vaccine?
3. Have you ever had an allergic reaction to acomponent of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
4. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
5. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
6. Have you received any vaccine in the last 14 days?
7. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
8. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
9. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
10. Do you have a bleeding disorder or are you taking a blood thinner?
11. Are you pregnant or breastfeeding?

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

	Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. 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 Form.
I understand that I will be receiving the vaccination at no cost to me.

Check each box

I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet, a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. 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 Form.

I understand that I will be receiving the vaccination at no cost to me.

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

Clear
Date Signed

MonthDay Year
Date
IMPORTANT: After hitting "Submit Consent Form (required)" please make sure you receive an email stating that we have received your response. If you do not recieve a response, you are NOT booked for an appointment.
Should be Empty:

Moderna COVID-19 Vaccine Consent Form