mNexspike +/- FLU

mNexspike Fall 2025
Age of person to be vaccinated (must be 12 or older on date of appointment)
Your child is too young for this vaccine. Please sign up for Spikevax (ages 5yr-11yr)
If you are between the ages of 12 and 64, to be eligible for this vaccine you must have at least 1 underlying medical conditions listed below:
- Cancer,
- Cerebrovascular disease (eg stroke)
- Chronic Kidney Disease (CKD)
- Chronic Liver Disease
- Chronic Lung Disease (asthma, COPD, bronchiectasis, bronchopulmonary dysplasia, damaged or scarred lung tissue [interstitial lung disease including idiopatic pulmonary fibrosis], pulmonary ebolism, pulmonary hypertension)
- Cystic fibrosis
- Dementia or other neurological conditions (eg Parkinson's Disease)
- Diabetes (Type 1 or 2)
- Disabilities (including ADHD, cerebral palsy, birth defects, learning disabilities, spinal injuries, Down Syndrome)
- Heart conditions (heart attack, arrhythmia, heart failure)
- Hemoglobin blood disorders (Sickle Cell Disease, Thalassemia)
- HIV Infection
- Immunocompromised (due to chemotherapy, solid organ transplant, long-term steroid treatment, or primary immunodeficiency)
- Mental health conditions (depression, schizophrenia spectrum disorders)
- Obesity (BMI 25kg/m2 or greater)
- Physical inactivity
- Smoking- current or former
- Solid organ or blood stem cell transplant
- Substance Use Disorder (alcohol, opioid, or cocaine use disorder)
- Tuberculosis
If you do not have any of these medical conditions, but care for or live with an individual(s) with one or more of the above listed medical conditions you should also be eligible for this vaccine.
I have read over the medical conditions listed above and attest that I am eligible for this vaccine, and/or I have had a discussion with my healthcare provider and have decided that I would like to be vaccinated.

YesNo
You will need to attest that you are eligible for this vaccine before you can proceed.

Date of most recent Covid-19 vaccine (must be at least 3 months from most recent COVID-19 vaccine)

MonthDayYear
Date
Would you/your child also like to get a flu shot today?*

No thanksYes, I am/my child is younger than 65 and would like a regular dose flu shot
Would you also like to get a flu shot today?

No thanksYes, given that I am 65 or older I would like a HIGH DOSE flu shot

Demographic Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Gender at Birth*
Race*
Ethnicity*

Consent
Please read each statement and check each box. Once this section is completed you will be prompted to sign the form.

Rows	Check each box
I understand the benefits and risks of the COVID-19 Vaccine and Seasonal Influenza Vaccine (if applicable) as described in the Vaccine Information Sheet, a copy of which I was provided with this consent form. I have had a chance to ask questions and they were answered to my satisfaction. I understand a vaccine, like any medication, is capable of causing serious problems such as severe allergic reactions. The risk of any vaccine causing serious harm or death is extremely small. I understand the benefits and risk associated with this vaccine. I believe that the benefits outweigh the risks and I request the vaccine be given to me or the person named above whom I am responsible for. Vaccine information sheets are available below.
I understand at this time, the FDA has approved this updated COVID-19 immunization for everyone over 65, and those individuals aged 12-64 with an underlying medical condition that puts them at a greater risk of bad outcomes with Covid-19 infection.
I agree to stay in the vaccine administration area until I am dismissed by an immunizer.
I understand that as required by state law, all immunizations will be reported to the Department of Public Health Massachusetts Immunization Information System (MIIS). I understand that I can access the MIIS Fact Sheet, which has been provided to me with this consent form, to get more information on the MIIS and what to do if I object to sharing of my/my child's immunization information.
I understand that once this vaccine is prepared for me/my child it cannot be undone. If I decide the vaccine will not be administered, I understand that Inman Pharmacy, INC will not reverse the claim through my/my child's insurance company and insurance is not guaranteed to pay for an additional claim.

Moderna Information for Recipients and Caregivers
VIS as of 1/31/2025
MIIS Fact Sheet
Signature of Person to Receive Vaccine (or parent/guardian if a minor): I attest that all of the information provided on this form is accurate. *
Date Signed*

MonthDayYear
Date

Insurance Information
mNexspike (and seasonal influenza vaccine if applicable) is commercially available. Our best guess is that it will be covered by insurance. Please select only one option below*

I/my child have insurance. By choosing this option I am authorizing Inman Pharmacy, INC to bill by medical or pharmacy insurance to cover the vaccine and vaccine administration cost. If my insurance does not cover the cost of the vaccine or administration I may be charged. I understand the pharmacy may contact me to obtain additional information if necessary.I/my child do not have insurance. I agree to pay out of pocket for the vaccine(s) and administration costs as applicable.
Please upload a copy of your insurance card. If you have Medicare Part B, please upload that card. If you do not wish to upload a copy of you card, we recommend you call the pharmacy with the information to ensure coverage prior to your appointment.

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Schedule Your Appointment
We are located at 1414 Cambridge Street (Inman Square) Cambridge, MA 02139. When you arrive for you appointment, please check in at the register. Once you are checked in you will be directed to the immunization area. We will need access to your the deltoid region of your shoulder. Please plan your dress accordingly. If you have any questions, or would like to cancel/change your appointment please call the pharmacy at (617) 876-4868
Appointment*
Should be Empty:

mNexspike Fall 2025

Demographic Information

Screening Questions

Consent

Insurance Information

Schedule Your Appointment