Required fields are marked with *

Other fields are not required and can be completed on the day of the clinic. However, completing all fields will help streamline the registration process.

I attest I am eligible to receive the COVID-19 vaccine and fall into one of the categories below:*

A healthcare worker A 1B frontline essential worker (firefighter, police officer, corrections officer, grocery store worker, food and agriculture worker, public transit worker, education sector) A 1C essential worker (restaurant workers, food suppliers, financial institutions, mechanics, electrical contractors, construction workers, hospitality workers) 65 years of age or older 18 to 64 years of age with a high risk medical condition (on dialysis, oxygen or chemotherapy)

Patient's Full Name*

Prefix First Name Middle Name Last Name

Gender*

Date of Birth*

Date

Phone Number*

E mail

Confirmation Email example@example.com

Address*

Street Address

Street Address Line 2

City State

ZIP code

Ethnicity*

Hispanic or Latino Not Hispanic or Latino Unknown / Not Reported

Race*

Primary Insurance

Insurance ID

Name of Primary Care Provider

Recipient Name (p 2)

Date of Birth (p 2)

Consent for Service

I verify that I have been provided with and have read (or had read to me) (1) the Fact Sheet for Recipients and Caregivers for the Emergency Use Authorization (EUA) of the Moderna COVID-19 vaccine (“Vaccine”); (2) this Moderna COVID-19 Vaccination Consent and Release Form; and (3) any additional information provided to me concerning COVID-19 vaccination. I acknowledge that I have had a chance to ask questions of a healthcare professional about the Vaccine. I understand that the Vaccine will be given in two separate doses, at least four weeks apart. I understand the known risks and the potential benefits of receiving the Vaccine, and I understand there may be risks to the Vaccine that are not known at this time. I understand that the FDA has authorized use of the Vaccine under an Emergency Use Authorization (EUA) and that there is currently not enough scientific evidence available for the FDA to fully approve this or any other COVID-19 vaccine. I nonetheless request and consent to the Vaccine being given to me.

Please initial that you have read and agree to Consent for Service.

Clear

Limitation of Liability

I understand that because this is not an FDA-approved vaccine but is being given under an FDA issued Emergency Use Authorization, KTA Super Stores, its divisions and affiliates and their respective officers, directors, employees, agents and representatives are immune from civil liability under federal and state law for all claims for loss related to any known or unknown side effects and/or injuries, including but not limited to death, that I, or the person for whom I am authorized to make this request, may experience from this vaccine. This immunity means that if I file a lawsuit against KTA Super Stores, the court must dismiss any such lawsuit, and the only exception to this immunity is for claims for willful misconduct.

Please initial to acknowledge you have read and understand the Limitation of Liability.

Clear

Authorization to Release Information for Medical Treatment and/or Payment

I understand that I am giving KTA Super Stores permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable CPESN Hawaii to process my insurance claims with respect to the vaccination.

Please initial to acknowledge you have read and understand the Authorization to Release Information for Medical Treatment and/or Payment

Clear

Recipient/Parent/Legal Guardian/POA Name

Signature of Recipient/Parent/Legal Guardian/POA

Clear

Date Signed

Date

Please indicate which dose you are scheduling an appointment for:*

Dose #1 Dose #2

Please Choose An Appointment Time*

Would you like to complete the prevaccination checklist for COVID-19 vaccines in order to expedite the registration process?*

Yes No, I will complete it at the clinic.

COVID-19 Moderna Vaccination Clinic Consent and Scheduler