COVID-19 Moderna BIVALENT Booster Appointment Form for Tuesday 5/30/23
You MUST bring your vaccine card to your booster shot appointment, your driver's license or ID, and your insurance card(s).
We have the Moderna COVID-19 BIVALENT Vaccine Available for all boosters. Please review eligibility.
BIVALENT ELIGIBILITY (as of 5/1/23)
The eligibility of Bivalent doses varies by age, vaccine manufacturer, previous COVID-19 vaccines received, and the presence of moderate or severe immune compromise. Contact your health provider if you are uncertain. As of May 1, 2023 the CDC has approved a 2nd Bivalent dose for those 65+ years, who received their last Bivalent dose at least months prior. Or immunocompromised patients 12+ years who received their Bivalent booster at least 2 months ago.
Vaccine Recipient Name
Are you requesting a first or second dose of the Moderna Bivalent Booster?
1st Bivalent Dose
2nd Bivalent Dose
Vaccine Recipient Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Email (put email@example.com if you don't have one)
Native American or Alaskan
African American or Black
Native Hawaiian or Pacific Islander
Other or multi-racial
Sex assigned at birth
PLEASE FILL THIS OUT AS THOUGHOUGHLY AS POSSIBLE
Medicare B (red white and blue card)
Name of Your Primary Insurance Company (put UNISURED if not insured)
If Private, Medicaid, or Medicare Part D please fill out below:
Rx Bin: (put N/A if not applicable)
ID #: (put N/A if not applicable)
Cardholder Status: (put N/A if not applicable)
Rx Group # (put N/A if not applicable)
If Medicare Part B (Red/White/Blue card) please provide card number below:
Medicare Part B (Red/White/Blue card) number: (put N/A if not applicable)
Primary Care Physician: Name, Address, Phone Number, put N/A if not applicable
I will read, or have explained to me, the information sheet about the COVID-19 vaccine or booster on the day of my appointment. I understand I will have a chance to ask questions to be answered to my satisfaction (and ensured the person named above for whom I am authorized to provide surrogate consent was also given a chance to ask questions). I understand the benefits and risks of the vaccination as described. I request that the COVID-19 booster vaccination be given to me (or the person named above for whom I am authorized to make this request and provide surrogate consent). I understand there will be no cost to me for this vaccine. I understand that any monies or benefits for administering the vaccine will be assigned and transferred to the vaccinating provider, including benefits/monies from my health plan, Medicare or other third parties who are financially responsible for my medical care. I authorize release of all information needed (including but not limited to medical records, copies of claims and itemized bills) to verify payment and as needed for other public health purposes, including reporting to applicable vaccine registries.
Legal Guardian Signature (if patient under 18 yrs)
Should be Empty: