Dripping Springs Pharmacy Vaccine Appointments

Dripping Springs Pharmacy Vaccine Appointments

100 Commons Road Suite 1 Dripping Springs, Texas 78620
Thank you for choosing Martin's Wellness and Compounding Pharmacies for your vaccines! You can book an appointment for 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.

Patients under 14 years old may require a prescription from their physician for certain vaccines. Please ask your child's physician to send a prescription to our pharmacy prior to your appointment. Patients under 3 years old require a prescription from their physician for all vaccines, including COVID-19 and flu vaccines. Patients aged 3 to under 14 require a prescription for all vaccines except COVID-19 and flu vaccines.

To cancel an appointment, please email info@martinswellness.com with which location, appointment date and time, and name.

Flu Vaccine Update:

We have the 2024-2025 flu shots in stock! With this flu season, CDC recommended moving to Trivalent Flu Vaccines for all flu vaccines.

COVID-19 Vaccine Update:

We have the 2024-2025 COVID-19 Moderna vaccine in stock! Appointments are subject to availability.

Appointment
Vaccine Appointment*
Pfizer 6M-4Y Vaccine Appointment
Which Dose of Pfizer 6M-4Y?

Dose 2 (at least 3-8 weeks after Dose 1)Dose 3 (at least 8 weeks after Dose 2)Booster

Patient Demographics

Patients < 3 years old require a prescription from their physician for all vaccines, including COVID-19 and flu vaccines. Patients ages 3 to under 14 years old require a prescription from their physician for all vaccines except COVID-19 and flu vaccines.
Appointment Date

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Date of Birth*

MonthDayYear
Age at time of appointment (in years)
Gender*

MaleFemaleOther
Email*
example@example.com
My child is < 3 years old. By initialing below, I acknowledge that my primary care provider must send our pharmacy a prescription for my child's vaccine being requested PRIOR TO THEIR VACCINE APPOINTMENT. Children less than 3 years old require a prescription for vaccines to be administered at our pharmacy and we are unable to administer the vaccine without a prescription from your primary care provider.*

Clear
My child is < 7 years old. By initialing below, I acknowledge that my primary care provider must send our pharmacy a prescription for my child's flu vaccine being requested PRIOR TO THEIR VACCINE APPOINTMENT. Children ages 3 to under 7 years old require a prescription for vaccines to be administered at our pharmacy for any vaccine other than COVID-19 vaccines and we are unable to administer the vaccine without a prescription from your primary care provider.*

Clear
My child is < 14 years old. By initialing below, I acknowledge that my primary care provider must send our pharmacy a prescription for my child's vaccine being requested PRIOR TO THEIR VACCINE APPOINTMENT. Children ages 3 to under 14 years old require a prescription for vaccines to be administered at our pharmacy for any vaccine other than flu or COVID-19 vaccines. We are unable to administer the vaccine without a prescription from your primary care provider.*

Clear

Insurance
Do you have insurance?*

I have Medicare Part B (Red, White, and Blue Medicare A/B card with letters and numbers)I have commercial PRESCRIPTION insuranceI have Medicaid insuranceI have no insurance
What is your Medicare Number?
Letters and numbers on your Red, White, and Blue Medicare Part A/B card
What is your Medicaid ID?
Prescription Insurance Card
Please attach a picture of your prescription insurance card.

Browse Files

Cancelof
Please attach a picture of your medical insurance card.

Browse Files

Cancelof
Zip code for insured
Please bring a copy of your insurance card(s) with you to your appointment.
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

MonthDayYear
Date
Dripping Springs Pharmacy Consent Form

Authorization and Consent
Unfortunately, you are not eligible for this dose of the COVID-19 vaccine at this time. Please check back to our website later.
Unfortunately, you are not eligible for this vaccine at this time due to age limits. Please check back to our website later.
We are currently out of the 2024-2025 Moderna 6 months-11 years old vaccine at our pharmacy. Please check back to our website later.
Age
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 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, 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 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 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 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 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
Should be Empty:

	YES	NO	DON'T KNOW	Notes
1. Are you sick today or have you had any COVID-19 symptoms or COVID-19 exposures in the past 10 days? Symptoms include: fever (100.4⁰F or above), chills, cough, shortness of breath, difficulty breathing, fatigue, muscle/body aches, headache, new loss of taste or smell, sore throat, congestion, runny nose, nausea/vomiting, or diarrhea.
2. Have you ever fainted after a vaccine, had an allergic reaction to a vaccine component (PEG, polysorbate, egg, thimerosal), or had a severe allergic reaction (anaphylaxis) to anything?
3. Do you have a history of or a risk factor for a blood clotting disorder?
4. Are you moderately or 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, and/or treatment with high-dose corticosteroids or drugs that suppress your immune response.
5. Have you ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness), a brain disorder, or a seizure disorder?
6. For Women: Are you pregnant or are you considering becoming pregnant?

Dripping Springs Pharmacy Vaccine Appointments

Vaccine Selection

Appointment

Patient Demographics

Insurance

Screening Form

Authorization and Consent