26-27 mNexspike +/- FLU

mNexspike +/- FLU Fall 2026
Age of person to be vaccinated (must be 12 or older on date of appointment)
Your child is too young for this vaccine. We can administer vaccine to children age 5 and older. If your child is between the ages of 5 years and 11 years of age, please sign them up for Spikevax Ages 5-11yrs

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you received a Covid-19 vaccine in the last 3 months?
You are not eligible to get a Covid-19 vaccine at this time.

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

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
2 digit month, 2 digit day, 4 digit yearDate
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 understand that the MA Department of Public Health has recommended that all person 19-64 should receive 1 dose of Covid-19 vaccine and all adults 65 and older should receive 2 doses of Covid 19 vaccine, the second dose administered 6 months after the first.
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
2 digit month, 2 digit day, 4 digit yearDate

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
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.

Cancelof

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 +/- FLU Fall 2026

Demographic Information

Screening Questions

Consent

Insurance Information

Schedule Your Appointment