Alden Pharmacy Vaccine Form
All sections marked with an asterisk (*) must be completed to schedule a vaccination appointment. Please have your insurance cards available to complete this form.
What vaccine are you scheduling? (select all that apply)
*
High-Dose Flu - Fluzone HD Quad (age 65 and up)
Flu - Fluzone Quad (age 3 and up)
Pneumonia - Prevnar 20
Shingles - Shingrix
Tetanus, Diphtheria, acellular Pertussis (TDaP) - Boostrix
RSV - Arexvy (age 60 and up)
How many doses of Moderna or Pfizer COVID-19 vaccine have you received?
*
0
1
2
3
4
What was the date of your first Moderna/Pfizer COVID-19 vaccine dose?
*
What was the date of your last Moderna/Pfizer COVID-19 vaccine dose?
*
How many doses of the Janssen (J+J) vaccine have you received?
*
0
1
What was the date you received the Janssen (J+J) vaccine
*
Appointment arrival time (please plan to spend about 20 minutes on site for your appointment). Following vaccination you must wait for 15 minutes to be monitored for any signs of an allergic reaction.
*
By typing my name, I certify that I am eligible to receive a COVID-19 vaccine based on the current CDC recommendations
*
Type first and last name
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Alden Pharmacy COVID-19 Immunization Screening and Consent Form
Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Transgender Male
Transgender Female
Non-Binary
Other / Prefer not to respond
Date of birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
County of residence (e.g. Erie)
*
Email Address (required if you want a confirmation email of your appointment)
example@example.com
Name of Primary Care Provider (Your doctor)
*
Type None if you do not have a PCP
Phone Number of Primary Care Provider
Please enter a valid phone number.
Do you have insurance?
*
Yes
No
I certify that I will bring my government issued photo ID and my social security number so that Alden Pharmacy can bill the Uninsured Program for the cost of administering the COVID-19 vaccine.
*
Yes
Do you have a Medicare card? (red, white, and blue card)
*
Yes
No
What is your Medicare ID number? (Use the card most recently issued to you, not the card with your social security number)
*
What is the name of your insurance plan for pharmacy coverage? (this may be a different card than your medical coverage)
*
What is your insurance Rx Bin number? (this is a six digit number that may be on the front or back of your insurance card)
*
What is your insurance Rx group number?
*
What is the phone number to the insurance plan?
*
Please enter a valid phone number.
What is your insurance ID number?
*
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Do you consent to having your vaccination record shared with the New York State Immunization Registry?
*
I consent
I do not consent
I agree to bring my insurance card(s) to my appointment
*
I agree
I understand that the COVID-19 vaccine is being administered under an FDA Emergency Use Authorization order and that the vaccine is not yet FDA-approved. A copy of the EUA is available on the Alden Pharmacy website. I am consenting to receive this vaccine.
*
I consent
I understand that once I hit the Submit button I will receive a confirmation screen to confirm my appointment. If I do not receive a confirmation screen, then the appointment time I selected is full and I would need to start over selecting a new appointment time.
*
I understand
Submit
Should be Empty: