Spikevax ages 5-11 years Fall 2025

Spikevax ages 5-11 years Fall 2025
Age of person to be vaccinated (must be between the ages of 5 and 11 on the date of the appointment
Your child is too young to receive this dose from us. We suggest you contact their pediatrician to determine next steps.
Your child is too old to receive this dose, please sign up for the 12+ version, mNexspike (if previously vaccinated) or Spikevax (if never had a COVID-19 vaccine)
If your child is between the ages of 5 and 11, to be eligible for this vaccine you must have at least 1 of the 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 your child does not have any of these medical conditions, but lives with an individual(s) with one or more of the above listed medical conditions they should also be eligible for this vaccine.
I have read over the medical conditions listed above attest that my child is eligible for this vaccine, and/or I have had a discussion with my child's healthcare provider and have decided it is in their best interest to be vaccinated.

YesNo
You must attest that your child is eiligible for the vaccine to proceed.

Date of most recent Covid-19 vaccine (must be at least 2 months since most recent dose of COVID-19 vaccine)*

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

No thanksYes please

Demographic Information
Child's Name*

First NameLast Name
Parent/Guardian's Name*

First NameLast Name
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian's Phone Number*
Please enter a valid phone number.
Parent/Guardian's Email
example@example.com
Child's Date of Birth*

MonthDayYear
Date
Child's Gender at Birth*
Child's Race*
Child's Ethnicity*

Consent
Please read each statement and check each box. Once this section is completed you will need to sign at the bottom of the page.

Type a question*

	Read each statement and 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 children aged 5-11 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 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 insurance company and insurance is not guaranteed to pay for an additional claim.

Spikevax Information for Recipients and Caregivers
VIS as of 1/31/2025
MIIS Fact Sheet
Signature of Parent/Guardian*

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Date Signed*

MonthDayYear
Date

Insurance Information
Spikevax (and seasonal influenza if applicable) is commercially available. It should be covered by your pharmacy insurance.*

My child has insurance. By choosing this option I am authorizing Inman Pharmacy, INC. to bill my pharmacy insurance to cover the vaccine(s) and administration cost. If my insurance does not cover the cost of administration I may be charged. I understand the pharmacy may contact me to obtain any additional information if necessaryMy child does 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*
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Spikevax ages 5-11 years Fall 2025

Demographic Information

Screening Questions

Consent

Insurance Information

Schedule Your Appointment