Vaccine Consent Form
In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.
Please select the type of vaccine you or the patient would like to receive:
*
Flu Vaccine (2 Years & older) Free if covered by insurance with our pharmacy otherwise $40
Flu Vaccine High Dose (65 years & older)
COVID SPIKEVAX
Select an appointment time for the Flu Shot (Parent/legal guardian should be present to provide consent if less than 18 years of age)
*
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Apt #
City
State Initials
Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
*
Mother's Maiden Name
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
*
Relationship to Emergency Contact
*
Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster child
Stepchild
Care Giver
Other
Phone Number of Emergency Contact
*
Email
*
example@example.com
Which arm would you like to get the injection on
*
Left Arm
Right Arm
The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.
Please Upload Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
For uninsured patients, please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Please Upload Supporting Uninsured Document
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Choose a file
Cancel
of
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Date Signed
/
Month
/
Day
Year
Date
Pharmacist Name
First and Last Name
Pharmacist Signature
Immunizer Name
First and Last Name
Immunizer Signature
Lot Number
Expiration Date:
Pharmacy Name
Submit
Pharmacy NPI
*
Should be Empty: