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. 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.

COVID-19 Vaccine Updates

3/29/22 The Food and Drug Administration (FDA) authorized a second booster dose of either the Pfizer or the Moderna COVID-19 vaccines for individuals 50 years and older and certain immunocompromised individuals. Following this, the Centers for Disease Control and Prevention (CDC) has updated its clinical recommendations to include the following:
- A second booster dose of the Pfizer or Moderna COVID-19 vaccine may be administered to individuals 50 years of age and older at least 4 months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine.
- A second booster dose of the Pfizer COVID-19 vaccine may be administered to moderate to severely immunocompromised individuals 12 years of age and older at least 4 months after receipt of a first booster dose of any authorized or approved COVID-19 vaccine.
- A second booster dose of the Moderna COVID-19 Vaccine may be administered to moderate to severely immunocompromised individuals 18 years of age and older at least 4 months after the first booster dose of any authorized or approved COVID-19 vaccine.
- In addition, adults who received a primary vaccine and booster dose of Johnson & Johnson’s Janssen COVID-19 vaccine at least 4 months ago may now receive a second booster dose using an mRNA COVID-19 vaccine.
For more information, please see the CDC's website for more information about COVID-19 boosters.

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

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 another dose of the COVID-19 vaccine at this time. Please check back to our website later.
Unfortunately, you are not eligible for the COVID-19 vaccine at this time due to age limits. Please check back to our website later.
Age

Vaccine	Age Minimum
Pfizer COVID-19	5 years old
Moderna COVID-19	18 years old
Janssen/J&J COVID-19	18 years old
Pfizer COVID-19 Booster Dose	12 years old
Moderna/J&J COVID-19 Booster Dose	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 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) *

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	YES	NO	DON'T KNOW	Notes
1. Are you sick today or have you had any COVID-19 symptoms in the past 2 weeks?
2. In the past 2 weeks, 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 (i.e. active cancer treatment for tumors or blood cancers, organ transplant, advanced/untreated HIV infection, taking high-dose corticosteroids or immunosuppresants)?
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