• 626-335-2300
  • 626-914-0713
  • 210 S Grand Ave Unit 116, Glendora, CA 91741

    Personal Information



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    Insurance Details

    Your insurance will be charged for the costs of administering your vaccination. If you have Medicare insurance, please provide your red, white and blue Medicare card.

    Click here to review the Moderna COVID-19 Fact Sheet: 

    VACCINE INFORMATION FACT SHEET

    Health and Medical History

    • Cancer

    • Chronic Kidney Disease

    • COPD (Chronic Obstructive pulmonary disease)

    • Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies

    • Immunocompromised state (weakened immune system) from solid organ transplant

    • Obesity (body mass index [BMI] of 30 kg/m2 or higher but < 40 kg/m2)

    • Severe Obesity (BMT >= 40 kg/m2)

    • Pregnancy

    • Sickle Cell disease

    • Smoking

    • Type 2 diabetes mellitus

    You will need to show proof of identity at your appointment. Examples include:

    • Driver’s license

    • California ID card or REAL ID card (from the DMV)

    • Military ID

    • Passport 

    **If you are attending for your second or third dose, please bring your white vaccine record card AND a photo ID.**

    I attest that the above information is true and correct to the best of my knowledge. I hereby give my consent to the licensed healthcare provider administering the vaccine, as applicable, to share my personal, demographic and health condition information in order to provide me with vaccination services for the COVID-19 vaccine.

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