Vaccine Clinic Registration Form

Vaccine Clinic Registration Form

Read and answer every question before scheduling your appointment
Autumn 2023 Mercury Pharmacy offers vaccination appointments for our customers by appointment only. The clinic is located at 22316 70th Ave W suite C in Mountlake Terrace (next door to Mercury Pharmacy). The vaccinator can administer doses in the parking lot/cars if necessary.

Mercury will stock influenza vaccines and the newest COVID vaccine made by Moderna. Other vaccines available upon special request.

Many people with chronic health conditions are at a higher risk of hospitalization from a viral infection. Annual flu shots protect your immune system from influenza and are recommended during the winter months. The COVID-19 vaccine will reduce the risk of acquiring the new strains of Coronavirus that have spread across the world. After receiving vaccines, it can take a few weeks for your body to build up protection from viruses. The protective antibodies will reduce the liklihood of infection as well as reduce the severity of an infection. Vaccines can have some side effects, like fatigue or muscle aches. If you think you are experiencing any side effects, please remain calm and contact your doctor immediately.

To contact us with question's regarding vaccines contact us at (425) 673-5200 and press 6.
Personal Information
First Name*
Last Name*
Birth Date*

MonthDayYear
Date
Email*
example@example.com
Please select the vaccine(s) you would like to get during your appointment:*

Fluupdated Moderna
Appointment*
By submitting this form, I declare that the information I have provided is correct.

You are required to bring to your appointment:
- Vaccine consent form (embedded below and available at the pharmacy clinic)
- A copy of your health insurance card and legal ID (if not submitted to the pharmacy in advance).
Should be Empty:

Vaccine Clinic Registration Form

Personal Information