Request an Appointment
COVID-19 Vaccine
** Please Note: We are currently ONLY administering the Johnson & Johnson COVID-19 vaccine.**
Patient Information
Name
*
First Name
Last Name
Gender
*
Female
Male
Prefer not to answer
Date of Birth
*
Phone Number
*
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a current patient at Medicine Mart Pharmacy of West Columbia?
*
Yes
No
Unsure
Insurance Information
PLEASE upload an image (utilizing the "Browse Files" option or the "Take Photo" option) of your Prescription Insurance Card or Medicare Part B (red, white, & blue card). THIS INFORMATION WILL BE VERY HELPFUL IF PROVIDED VIA THIS FORM PRIOR TO YOUR APPOINTMENT.
Do you have prescription insurance?
*
Yes -- please enter your information below utilizing 1 of the 3 options
No
Browse Files - If you have an issue uploading an image, you may type in your information below.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Take Photo - If you have an issue uploading an image, you may type in your information below.
Medicare Part B
Ex: 1AB2-C3D-EF45
Prescription Insurance Card Information
Appointment Calendar
Select an Appointment Date
*
Vaccine Screening
If you have received a dose of COVID-19 vaccine, please indicate which manufacturer you received & when your first dose was received.
Consent (check each box after reading & agreeing)
*
Check each box
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Johnson & Johnson Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.
Please sign below.
*
Clear
You will receive an email confirmation after submission.
Please bring your photo ID and insurance cards to your appointment & wear a short-sleeved shirt.
Submit
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