Lamar Plaza Drug Store Vaccine Appointments

Lamar Plaza Drug Store Vaccine Appointments

1509 South Lamar Boulevard Suite 550 Austin, Texas 78704
Thank you for choosing Martin's Wellness and Compounding Pharmacies for your vaccines! You will now be able to book any vaccine at our pharmacies, subject to availability. Appointment times will be for a maximum of 2 vaccines at a time. If you need 3 or more vaccines, please book an additional appointment time through this same link.

COVID-19 Vaccines

COVID-19 vaccines for ages 5-11 are NOT approved by FDA or CDC at this time and cannot be given at our pharmacies. We must receive approval from both FDA and CDC for us to begin administering the vaccine.

Pfizer and Moderna COVID-19 Booster Update 10/22/21: For individuals who received a Pfizer-BioNTech or Moderna COVID-19 vaccine, the following groups are eligible for a booster shot at 6 months or more after their initial primary series:
- 65 years and older
- Age 18+ who live in long-term care settings
- Age 18+ who have underlying medical conditions
- Age 18+ who work or live in high-risk settings
For more information, please visit the CDC's website about boosters HERE.

Janssen/Johnson & Johnson Update 10/22/21: People that received their Janssen/J&J are eligible to get their booster shots if vaccinated two or more months ago

Moderna and Pfizer COVID-19 Additional Dose: People that are moderately to severely immunocompromised are eligible for an additional dose of Moderna and Pfizer at least 28 days after your second dose and it must be the same vaccine that you received during your first and second doses. For more information, please visit the CDC's website about third doses for immunocompromised people HERE.

Appointment
Appointment *
Appointment Date

Month Day Year
Date

Patient Demographics
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Date of Birth *

Month Day Year
Sex *

Male Female Other
Email *
example@example.com
To decrease wait times in the pharmacy, would you like to fill out your consent form today? *
If you answer NO, please arrive at the pharmacy at least 10 minutes prior to your appointment to complete your paperwork

Vaccine Administration Information

	Vaccine	Lot	Expiration	Mfg/Dose	Inj Site	Dose/VIS
COVID-19
Flu
Other
Other

Immunizer Signature
Date Vaccine(s) Administered

Month Day Year
Date

Authorization and Consent
Unfortunately, you are not eligible for another dose of the COVID-19 vaccine at this time. Please check back to our website later.
Unfortunately, you are not eligible for the COVID-19 vaccine at this time due to age limits. Please check back to our website later.
Age

Vaccine	Age Minimum
Pfizer COVID-19	12 years old
Moderna COVID-19	18 years old
Janssen/J&J COVID-19	18 years old
Flu	3 years old (6 months and older with a prescription)

I acknowledge that I understand the benefits and risks of the requested vaccination as described in the Vaccine Information Sheet or Emergency Use Authorization Fact Sheet, a copy of which is provided with this Consent and Release. I confirm that Dripping Springs Pharmacy or Lamar Plaza Drug Store has answered to my satisfaction all of my questions about the vaccine and the vaccination procedure. I request and consent that the vaccination be given, as I direct Dripping Springs Pharmacy or Lamar Plaza Drug Store, either to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release. I understand that I am giving Dripping Springs Pharmacy or Lamar Plaza Drug Store permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company or immunization registry, as applicable, to enable Dripping Springs Pharmacy or Lamar Plaza Drug Store to process my insurance claims with respect to the vaccination.

I, for myself (and for the recipient of the vaccination, if the recipient is a minor), my heirs, executors, and assigns hereby release Dripping Springs Pharmacy and Lamar Plaza Drug Store and its affiliates, owners, employees, agents, and representatives from any and all claims arising out of or in connection with the quality of the above-described vaccine(s) as provided by the manufacturer and any negligence of Dripping Springs Pharmacy or Lamar Plaza Drug Store in connection with the related injection of the vaccination. I understand that the laws of my state may affect my remedies in connection with this vaccination.
Signature of Person to Receive Vaccine(s) (or parent or guardian if recipient is < 18 years old) *

Clear
Pfizer Appointment
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

	YES	NO	DON'T KNOW	Notes
1. Are you sick today or have you had any COVID-19 symptoms in the past 2 weeks?
2. In the past 2 weeks, are you aware of being exposed to someone who tested positive for COVID-19?
3. Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
4. If you had COVID-19 in the past 3 months, did you receive monoclonal antibodies or convalescent plasma as part of your COVID-19 treatment?
5. Have you had a serious allergy to ANY medication, vaccine, or foods? This includes vaccines, food, pet, venom, environmental, or medication allergies. If YES, please list.
6. Are you moderately to severely immunocompromised? This includes receiving active cancer treatment for tumors or blood cancers, organ transplant recipient or stem cell transplant recipient within the last 2 years and on immunosuppressants, moderate or severe primary immunodeficiency (i.e. DiGeorge or Wiskott-Aldrich syndrome), advanced/untreated HIV infection, treatment with high-dose corticosteroids or drugs that suppress your immune response.
7. Do you have a history of or a risk factor for a blood clotting disorder?
8. Have you ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness), a brain disorder, or a seizure disorder?
9. For Women: Are you pregnant or are you considering becoming pregnant?

Lamar Plaza Drug Store Vaccine Appointments

Appointment

Vaccine Selection

Patient Demographics

Insurance and Screening Form

Authorization and Consent