Hen House #32 Vaccine Appointment Form

Hen House #32: 13600 S Blackbob Rd, Olathe, KS - Vaccine Appointment Form
- Please bring your pharmacy insurance or Medicare Part B card if insured to your vaccine appointment.
- Those who do not have insurance will be asked to pay a cash price for their vaccine(s).
I need to schedule:*

Flu ShotCOVID-19, Moderna (12+years)Hepatitis A/BHPVMeningococcalMMR (Measles/Mumps/Rubella)PneumoniaRSVShingles (Shingrix)Tetanus/Diphtheria/Pertussis (Tdap)
Please call our pharmacy for travel vaccine inquiries, including Yellow Fever, Typhoid, rabies, and more!

913-782-2039, option 0.
Respiratory Illness testing for:*

Influenza A/BStrep throat
If the respiratory test is positive for influenza or strep throat, the patient must be able and willing to wait for treatment to be dispensed by our pharmacist. Patient must be 6 years of age or older to receive treatment from the pharmacy per Kansas Law.

Influenza test: $39.99

Strep Throat test: $24.99
Appointment*
Vaccine Recipient Information
Name*

First NameMiddle NameLast Name
Age of person receiving vaccine: Age*years old
Phone Number*
Please enter a valid phone number.
Phone Type*
Email - will receive confirmation of appointment*
example@example.com
Name of Person Completing This Form (if not the Vaccine Recipient listed above):
Full Name
Relationship to Patient (if not the Vaccine Recipient):
Full Name
Should be Empty:

Hen House #32: 13600 S Blackbob Rd, Olathe, KS - Vaccine Appointment Form