Moderna Authorization & Consent
You are being offered the Moderna COVID-19 vaccine (2024-2025 formula) to prevent Coronavirus Disease 2019 (COVID-19) caused by SARS-CoV-2. The Fact Sheet contains information to help you understand the risks and benefits of the Moderna COVID-19 vaccine. The Fact Sheet may have been updated. For the most recent Fact Sheet, please see https://products.modernatx.com/spikevax.
The Moderna COVID-19 vaccine has been fully approved by the U.S. Food and Drug Administration (FDA) for individuals 12 years and older. It is available to those ages 6 months - 11 years under emergency use authorization. The Moderna COVID-19 vaccine may prevent you from getting COVID-19 but may not protect everyone, and there is no guarantee of complete immunity.
If you have questions about this vaccine, please call our nurse line at 816-404-6456.
Your signature indicates the following: I have been given a copy and have read, or have had explained to me, the information in the Fact Sheet for COVID-19. After being educated on the risks and benefits, I hereby consent to be inoculated with the COVID-19 vaccine. I have had a chance to ask questions that were answered to my satisfaction.