• This form is for scheduling vaccines that DO NOT relate to the COVID 19 virus. 

  • Immunization Consent Form

    Please have your pharmacy insurance card ready when completing
  • Payment

    Vaccines may be billed to your pharmacy benefits. Please contact your plan directly if you have questions regarding insurance coverage of vaccines.
  • Medicare Part B Insurance Card Information

    Please input each of the following for your insurance card
  • Colorado Medicaid

    Please enter your CO Medicaid ID Number
  • Insurance Card Information

    Please input each of the following for your insurance card
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  • Screening Questions

    For Patients: The following questions will help us determine which vaccines you may be given today. If you answer "Yes" to any question it does not necessarily mean you should not be vaccinated today. It just means additional questions maybe asked. If a question is not clear, please ask us to explain it.
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  • Consent to Vaccination

    I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Buena Vista Drug, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I accept responsibility for seeking medical attention for any problems associated with my receiving this vaccination. I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist. I understand that by signing below I am responsible for payment of this vaccination if my insurance company denies payment to Buena Vista Drug. If the vaccine was paid for by my employer I authorize the pharmacy to share this vaccine history with my employer.
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  • Appointments for vaccines is preferred but not required. Scheduling an appointment helps our team serve you best and to be prepared for when you arrive. After submiting your form you will be directed to a page to make an appointment. If you do not want to make an appointment you can close the window and we will still receive your submission. If you have any questions, please give us a call at 719-530-4790

  • Pharmacy Use Only

    Do no complete the below questions
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