Grass Lake Community Pharmacy Vaccine Appointment Sign Up
Vaccine Sign up for Covid-19, Flu Shot, Pneumonia, HepA, HepB, or Shingles. Two vaccines can be given in one appointment.
Appointment
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Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date Picker Icon
Name of Parent or Guardian
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Gender
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Male
Female
Email
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Confirmation Email
We ask everyone to confirm their email address in hopes to ensure they will receive their confirmation email for their appointment(s).
Phone Number
*
Please enter a valid phone number.
Race
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Please Select
Native American or Alaska Native
Asian
Black or African American
Pacific Islander or Native Hawaiian
White
Other
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select What Vaccine(s) You Wish To Receive (Maximum of 2 Vaccines per Appointment)
What Vaccine(s) Do You, Or Your Child, Need?
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FLU (Influenza) Vaccine
Hepatitis Vaccine (A or B)
Pneumonia Vaccine
Shingles Vaccine
Respiratory Syncytial Virus (RSV) ages 60 and up
Covid-19 Moderna Spikevax 2024-2025 FOR AGES 12 AND OLDER
COVID-19 Vaccine: Select What Vaccine & Type You Wish To Receive
Moderna BOOSTER Dose *NEW Bivalent*
Kids Pfizer Vaccine BOOSTER Dose (Age 5-11)
Pfizer Vaccine BOOSTER Dose (12+) *NEW Bivalent*
FLU Vaccine: Select the flu vaccine you wish to receive
Fluzone (6 Months & Older)
Fluzone HD (65 Years & Older)
PNEUMONIA Vaccine: Select the vaccine you wish to receive
Prevnar-20
Pneumovax 23
HEPATITIS Vaccine: Select the vaccine you wish to receive
(HepA) Havrix
(HepB) Recombivax
SHINGLES Vaccine: Select which dose you wish to receive
1st Dose
2nd Dose
OPTIONAL Upload Section
OPTIONAL UPLOADS SPEED UP APPOINTMENTS: upload photo IDs, prescription insurance, and Medicare cards to speed up your appointment. In case something is missed, or uploaded blurry, please bring these documents with you to your appointment.
Please Upload Your Drivers License or Photo ID
Browse Files
Drag and drop files here
Choose a file
This is an OPTIONAL field & can submit this form without uploading anything in this field. For those who do upload their license/ID please ensure all the information on the card uploaded is CLEAR. If we CANNOT READ the information on the card, we may need to reach back out to you in order to collect that information.
Cancel
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Please Upload Your Prescription Insurance Card, Ensure the "Rx" Symbol is on the Uploaded Card
Browse Files
Drag and drop files here
Choose a file
This is an OPTIONAL field & form can be submitted without uploading anything in this field. For those who do upload their Prescription Insurance Card please ensure the information on the card(s) uploaded is legible. If we cannot read the information on the insurance card, we may need to reach back out to you in order to collect that information.
Cancel
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If Applicable: Please Upload Your Medicare Card
Browse Files
Drag and drop files here
Choose a file
This is an OPTIONAL field & form can be submitted without uploading anything in this field. For those who do upload their Medicare Card please ensure the information on the card uploaded is legible. If we cannot read the information we may need to reach back out to you in order to collect that information.
Cancel
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General Vaccine Questions
Please Answer The Following Questions For Our Pharmacist
1. Do you, or your child, have ANY Allergies to a Vaccine Component being received, OR LATEX?
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Yes
No
2. Have you, or your child, had a Serious ALLERGIC REACTION to a VACCINE in the past?
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Yes
No
3. Have you, or your child, had a Serious ALLERGIC REACTION to ANYTHING in the past Such as medication, food, bees, etc.?
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Yes
No
4. Have you, or your child, ever had Guillain-Barre' Syndrome?
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Yes
No
5. Have you, or your child, ever had Cancer, Leukemia, HIV/AIDS, or any other immune system problem that your doctor may advise you, or your child, to avoid the vaccination?
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Yes
No
6. In the past 3 months, have you, or your child, taken medication that has weakened the immune system, such as Cortisone, Prednisone, other Steroids, Anticancer Drugs, or had Radiation treatments?
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Yes
No
7. Are you immunocompromised?
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Yes
No
For Those Receiving A FLU SHOT: Do You, Or Your Child, Have An Allergy to EGGS or Components of The Influenza Vaccines?
Yes
No
I Accept & Acknowledge That
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I am going to the Grass Lake Community Pharmacy located at 110 E. Michigan Avenue Grass Lake, MI 49240 according to the appointment schedule.
I CANNOT come to my vaccine appointment if I am feeling SICK. We cannot give a vaccine to anyone with COVID-19 symptoms, who is feeling ill, or has a FEVER.
I Need to Complete ONE Sign Up Form for EVERY person receiving a vaccine
I Need To WEAR A SHORT SLEEVE SHIRT, or clothing that allows the pharmacist or nurse to administer the vaccine on your Upper Shoulder/deltoid muscle.
I will bring my driver's license, or photo ID, prescription (Rx) Insurance card, and Medicare card (if 65+) even if uploaded (in case they are unclear or incomplete). If I do not bring my Medicare card, I will provide my Social Security Number to staff.
Signature of ADULT client or PARENT/GUARDIAN if a MINOR is being vaccinated
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Vaccine Administered, Lot Number, Expiration Date
Fluzone (6 mo and older) Lot# UT8038MA, Exp:06/30/2024
Fluzone 65+ Lot# UT8131CA, Exp: 06/30/2024
HEVRIX (HepA) Lot# 95DB2, Exp: 12/13/24
Prevnar 20 Lot# FN4179, Exp: 08/2023
PNEUMOVAX23 Lot# 4018309, Exp: 1/8/23
RECOMBIVAX (HepB) Lot# U004365, Exp: 04/28/23
SHINGLES (Shingrix) Lot# 7FBP, Exp: 11/23/23
Is the client sick today, or have a fever?
Yes
No
Location of FIRST Intramuscular Administration FLU
Left Arm
Right Arm
Location of *SECOND* Intramuscular Administration COVID-19
Left Arm
Right Arm
Pharmacist Signature
Notes about this vaccination/visit/billing (please initial and date your entry)
Submit
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