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. Book your flu shot at the same time as your COVID-19 bivalent booster vaccine! 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.

Children 3 and older do not need a prescription for the vaccine. Children UNDER THE AGE OF 3 need to ask their physician to send a prescription to our pharmacy prior to their appointment.

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

COVID-19 Vaccine Updates

Moderna and Pfizer BIVALENT booster appointments are available!

The updated Moderna booster is authorized for people 18 years of age and older. The updated Pfizer booster is authorized for use in individuals 12 years of age and older. Both can be given to people at least two months after the completion of any primary COVID-19 vaccine series, including Novavax and Janssen COVID-19 vaccines, or their most recent COVID-19 booster of any type.

The monovalent mRNA (Moderna and Pfizer) COVID-19 vaccines are no longer authorized as booster doses for individuals 12 years of age and older.

Appointment
Vaccine Appointment *

Patient Demographics
Appointment Date

Month Day Year
Date
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
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

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 insurance I have Medicaid insurance I 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
If you'd prefer to upload a picture of your insurance card(s), please attach a picture here:

Browse Files

Cancel of
Zip code for insured (if different than address)
Please bring a copy of your prescription insurance card with you to your appointment. It will include an RX BIN, RX PCN, RX Group ID, and RX Member/Cardholder ID.
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 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.
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
COVID-19 Pfizer (6M-4Y) and Moderna (6M-5Y) Vaccine Appointment
Should be Empty:

	YES	NO	DON'T KNOW	Notes
1. Are you sick today or have you had any COVID-19 symptoms in the past 10 days?
2. In the past 10 days, are you aware of being exposed to someone who tested positive for COVID-19?
3. Have you had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?
4. 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.
5. 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, and/or treatment with high-dose corticosteroids or drugs that suppress your immune response.
6. Do you have a history of or a risk factor for a blood clotting disorder?
7. Have you ever had Guillain-Barré Syndrome (a type of temporary severe muscle weakness), a brain disorder, or a seizure disorder?
8. For Women: Are you pregnant or are you considering becoming pregnant?

Dripping Springs Pharmacy Vaccine Appointments

Appointment

Vaccine Selection

Patient Demographics

Insurance

Screening Form

Authorization and Consent