• COVID Vaccine Consent Form - Urbandale

    * Please fill out the required details below
  • **AS OF JANUARY 25, 2021, WE ARE NOT ACCEPTING ANYMORE APPOINTMENTS DUE TO LOW VACCINE SUPPLY. WE WILL UPDATE THIS AS SOON AS WE HEAR ABOUT OUR SUPPLY. THANK YOU FOR YOUR PATIENCE.**

    If you have remaining questions, please call us at (515) 276-3471.

  • Section I. Personal Information

  •  /  /
    Pick a Date

  •  -  -
    Pick a Date
  • Section II. Questionnaire for Immunization

  •  
  • Section III. Appointment Scheduler

  • **AS OF JANUARY 25, 2021, WE ARE NOT ACCEPTING ANYMORE APPOINTMENTS DUE TO LOW VACCINE SUPPLY. WE WILL UPDATE THIS AS SOON AS WE HEAR ABOUT OUR SUPPLY. THANK YOU FOR YOUR PATIENCE.**

    At this time, we are only providing COVID-19 vaccines for Phase 1A.  Starting Jan. 25 we will begin scheduling Phase 1B which officially starts Feb 1. This includes: people aged 65 years and up, Healthcare Workers, First Responders, PK-12 educators and staff, childcare workers, and long term care residents and staff.  If the times are grey and cannot be selected, we are fully booked.  Every day at midnight another day a week in advance opens for appointments. 

  • Section IV. Signatures

    I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this Consent and Release. 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 and Release.

  • Clear
  • I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

  • Clear
  • Browse Files
    Cancel of
  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

    You will be required to provide proof of healthcare Phase1a employment (name badge, pay stub, etc.)

  • Should be Empty: