COVID-19 Vaccine Appointment

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Southern Pharmacy, in coordination with the Arkansas Department of Health, will be a participating COVID-19 vaccine provider. Vaccine distribution will follow the Arkansas Department of Health Vaccination Plan Map. The Arkansas Department of Health Vaccination Plan Map can be viewed here.

All Arkansans greater than 12 years of age are eligible to receive COVID-19 vaccines

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COVID-19 Third Doses

The CDC Advisory Committe on Immunizations (ACIP) has recommended COVID-19 vaccine third doses for Moderately to Severely Immunocompromised People

CDC guidelines regarding COVID-19 vaccine third doses can be viewed here:

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/immuno.html

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COVID-19 Booster Doses

CDC recommends that the following groups should receive a booster shot of Pfizer-BioNTech’s COVID-19 Vaccine at least 6 months after completing their Pfizer-BioNTech primary series (i.e., the first 2 doses of a COVID-19 vaccine):

people aged 65 years and older

residents aged 18 years and older in long-term care settings

people aged 50–64 years with underlying medical conditions

CDC also recommends that the following groups may receive a booster shot of Pfizer-BioNTech’s COVID-19 Vaccine at least 6 months after completing their Pfizer-BioNTech primary series, based on their individual benefits and risks:

people aged 18–49 years with underlying medical conditions

people aged 18–64 years at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting

CDC guidelines regarding COVID-19 vaccine booster doses can be viewed here:

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html

Please complete the COVID-19 Vaccine Appointment Request to schedule a COVID-19 vaccination

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Southern Pharmacy

COVID-19 Vaccination Appointment

Monday - Friday

10pm - 4pm

Location

3001 Apache Drive

Jonesboro

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Have you received you first dose of COVID-19 vaccine?* This field is required.
YESNO
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Have you received your second dose of COVID-19 vaccine?* This field is required.
YESNO
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Do you wish do schedule an appointment for COVID-19 vaccine booster?* This field is required.
YESNO
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Did you receive your first or second dose of COVID-19 vaccine from Southern Pharmacy?* This field is required.
YESNO
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Which COVID-19 vaccine did you receive?
Moderna
Pfizer
Johnson & Johnson
I do not remember
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Are you one of the following?CDC guidelines for COVID-19 vaccine third doses can be viewed here: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/immuno.html. CDC guidelines for COVID-19 vaccine booster doses can be viewed here: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html. Underlying medical conditions can be viewed here: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
Immunocompromised (Active cancer treatment, organ transplant or medications for organ transplant, stem cell transplant, medication to suppress immune system, moderate or severe primary immunodeficiency, Advanced or untreated HIV infection)
65 years of age or older
18 years and older in long-term care settings
50-64 years of age with underlying medical conditions
18-49 years of age with underlying medical conditions
18–64 years at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting
None of the above
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Would you like to receive a flu vaccine along with your COVID-19 vaccine?
YESNO
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Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Area Code
Phone Number
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EmailEmail will be used to confirm appointment time. NOT REQUIRED.
eexample@example.com
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COVID-19 Vaccine Appointment Time* This field is required.Please select a Test Appointment Time
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RELEASE AND ASSIGNMENT:

· I have read or had explained to me the Vaccine Recipient Emergency Use Authorization (EUA) Fact Sheet for COVID-19 vaccine risks and benefits. To read the Vaccine Recipient Emergency Use Authorization Fact Sheet for each vaccine visit the website https://www.cdc.gov/vaccines/covid-19/eua/index.html to view current EUA: or you may also visit the Local Health Unit or private provider to receive a printed copy of the EUA Fact Sheet.

· I give consent to this COVID-19 provider/staff for the individual named above to be vaccinated with COVID-19 vaccine.

· I hereby acknowledge that I have reviewed a copy of the Provider’s Privacy Notice.

· I understand that information about this COVID-19 vaccination will be included in (WebIZ) Arkansas Immunization Information System.

TO MY INSURANCE CARRIERS:

· I authorize the release of any medical information necessary to process my insurance claim(s).

· I authorize and request payment of medical benefits directly to this COVID-19 Provider.

· I agree that the authorization will cover all medical services rendered until I revoke the authorization.

· I agree that the photocopy of this form may be used instead of the original.

CONSENT TO NOTIFY:

I consent that Southern Pharmacy may contact me via email and/or sms message using the information provided. Contact information may include COVID-19 vaccine availability, COVID-19 vaccine appointment reminders, and other healthcare information.

View the Southern Pharmacy privacy policy here

PLEASE CLICK SUBMIT TO VERIFY CONSENT
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