**PLEASE READ ENTIRE FORM**

THE COVID-19 VACCINE BOOSTER HAS BEEN APPROVED.

**Please understand Smith Family Pharmacy has the right to cancel your appointment if you do not meet the criteria deemed necessary by the Arkansas Department Health Guidelines**

For Moderna vaccine boosters:

If any of the following apply to you AND it has been 6 months since your second dose, you may schedule your booster appointment:

1. You are 65 years of age or older

2. You are 18 to 64 years old with one of the following high risk factors: cancer, chronic kidney disease, chronic liver disease, chronic lung disease, dementia, diabetes, Down syndrome, heart conditions, HIV, immunocompromised state, mental health disorders, obesity, pregnancy, sickle cell disease, smoking (current or former), transplant patient, substance use disorders, tuberculosis

3. You are 18 to 64 years old with frequent exposure to COVID-19 through your occupation or institutional living

For Johnson & Johnson vaccine boosters:

If you are 18 years and older and it has been 2 months since your dose, you may schedule your booster appointment.

For new patients:
Please bring your insurance card, if you have it, and your photo ID. If you do not have insurance, you can still get the vaccine.

Please note that you will be REQUIRED to wait in our observation area for 15 minutes after you receive your vaccine. We ask that you plan accordingly.

For all patients:

If possible, please go to smithfamilypharmacy.com to the "FORMS" tab and complete the COVID-19 Vaccination Consent Form prior to your appointment.