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 will now be able to book any vaccine at our pharmacies, subject to availability.

Appointments will be available for all vaccines at our pharmacies, including COVID-19 vaccines, flu vaccines, travel vaccines, and childhood immunizations. 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.

Vaccines are available without a prescription for anyone age 3 and older. There are specific age limits for each vaccine. If you are booking an appointment for someone age 17 years and younger, parent/guardian consent is required. Please fill out the form for the person that will be receiving the vaccine.

COVID-19 Booster Update: We are still waiting on more information from ACIP and FDA before opening up appointments for boosters of Moderna and Pfizer. Once we receive approval to be able to administer COVID-19 booster vaccines, we will open up appointments on our website.

Moderna and Pfizer COVID-19 Third Dose: At this time, we are ONLY taking appointments for people that are moderately to severely immunocompromised 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 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.
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) *

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	YES	NO	DON'T KNOW	Notes
Are you sick today or have you had any COVID-19 symptoms in the past 2 weeks?
In the past 2 weeks, are you aware of being exposed to someone who tested positive for COVID-19?
Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
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?
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.
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.
Do you have a history of or a risk factor for a blood clotting disorder?
Have you ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness), a brain disorder, or a seizure disorder?
For Women: Are you pregnant or are you considering becoming pregnant?

Dripping Springs Pharmacy Vaccine Appointments

Appointment

Vaccine Selection

Patient Demographics

Insurance and Screening Form

Authorization and Consent