Please bring your insurance card to your appointment. While there is no patient responsible amount for COVID vaccines, we are able to bill your insurance for administering the vaccine.
If you do not have insurance, there is still no cost. However, we may request an ID at your appointment so we can get reimbursed from an uninsured fund.
As of 11/8/2021, we can no longer make flu appointments because we are out of vaccine.
Currently, CDC is recommending that moderately to severely immunocompromised people receive an additional dose. This includes people who have
People should talk to their healthcare provider about their medical condition, and whether getting an additional dose is appropriate for them.
If you fall into one of the categories above and have already received 2 doses of vaccine, please select 3rd dose below. Otherwise, if you have received 2 doses of Moderna or Pfizer vaccine (at least 6 months ago) or one dose of Johnson & Johnson (at least two months ago), select booster.
Have you ever had an allergic reaction to:
(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen(R) or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling or respiratory distress, including wheezing.)
The Public Readiness and Emergency Preparedness Act (PREP Act) authorizes the CICP to provide benefits to certain individuals or estates of individuals who sustain a covered serious physical injury as the direct result of the amdinistration or use of the covered countermeasures. The CICP can also provide benefits to certain survivors of individuals who die as a result of the administration or use of the covered countermeasures identified inthe PREP Act declaration. The PREP Act declaration for medical countermeasures against COVID-19 states thta the covered countermeasures are any antiviral medication, any other drug, any biologic, any diagnostic, any other device, or any vaccine used to treat, diagnose, cure, prevent, or mitigate COVID-19, the transmission of SARS-CoV-2 or a virus mutating from SARS-CoV-2, or any device used in the aministration of and all components and constituent materials of any product. Information about the CICP and filing a claim is available by calling 1-855-266-2427 or visiting:
https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/moderna-covid-19-vaccine (opens in new tab)
By signing below I acknowledge I have been provided with the CICP statement above, have been given the opportunity to review the Moderna Emergency Use Authorization located at: https://www.modernatx.com/covid19vaccine-eua/eua-fact-sheet-recipients.pdf and have been notified of Kilgore's Medical Pharmacy's Notice of Privacy Practices available at https://kilgoresrx.com/wp-content/uploads/2021/01/Hipaa-privacy-practices-2021-all-stores.pdf (both links open in new tabs).
Please review the vaccine information sheet(s) for the vaccine(s) you plan to receive:
(sheets will open in a new browser tab that can be closed to get back to this form).
I have read, or have had read to me, the written information regarding the vaccine(s) marked below. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet for each vaccine I am receiving today. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify and hold harmless Kilgore Inc, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s)marked below. I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Kilgore's Medical Pharmacy to administer thevaccine(s)marked below. If under 18 years old signature by parent or guardian required. I HAVE BEEN ADVISED TO WAIT 15 MINUTES FOR OBSERVATION AFTER VACCINE.
By signing below, I attest that I am eligible for a booster dose of a Pfizer or Moderna mRNA COVID-19 vaccine based on the criteria below.
I furthermore attest that I have previously received a two-dose series of Pfizer or Moderna mRNA COVID-19 vaccine.