Moderna SECOND Dose Questionnaire | MidCities Pharmacy
MidCities Pharmacy has been helping patients to get their second Moderna Vaccine doses at a convenient (and appropriate) time. We are receiving an extraordinary number of requests and to simplify this, we are asking you to complete this form so that we can assist in scheduling second dose requests.
Once we open a Moderna vial, we have to use the entire vial within 5 hours - that means that all 10 doses have to be used within that time frame. We will schedule at least 10 doses each time we open a vial. Additionally, Moderna recommends the the second dose be scheduled 28 days to up to 6 weeks from the first dose. Do know, that even with the first dose, the efficacy is approx 81% versus 95% with the second dose.
All vaccinations (unless being performed at an off-site location as previously arranged) will be at MidCities Pharmacy at 2000 Precinct Line Rd, Hurst, Texas 76054
If you have any questions, please email
. Please do not call the pharmacy at this time.
What is your name?
What is your address, city & zip?
What is your email? Make sure this is correct!
What is your MOBILE number?
Which Rx Insurance do you have?
TRICARE / Military
FEP BCBS (Federal Employees only)
OTHER (not Medicare)
If you have a prescription Rx card, what is the BIN and PCN on it?
DATE of FIRST MODERNA VACCINE?
Location of FIRST Moderna Dose Provider?
Any other specific notes
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