COVID-19 Vaccine Appointment Scheduling WESTOWN PHARMACY

455 Hartford Rd , Manchester , CT - 06040 Phone 8606499946 COVID-19 Vaccine Appointment Form
Select an appointment time*
Vaccine Recipient Name*

First NameMiddle NameLast Name
Vaccine Recipient Physical Address

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code
Date of Birth*

MonthDayYear
Gender at birth
Race
Ethnicity
Vaccine Recipient Phone Number*
Email
example@example.com
Check the one you like to have

MODERNA BIVALENT BOOSTERJANSSENPFIZER BIVALENT BOOSTERNOVAVAX 1ST DOSENOVAVAX 2 ND DOSE
Have you received a dose of COVID-19 Vaccine ? If yes, Manufacturer for the first dose received .
Required if you selected "Yes" to #2
Do You want get a FLU SHOT today ?*

YESNO

The vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following.*

	Check one
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.

For uninsured patients, please select at least one of the following that you will bring with you to your appointment.

Social Security NumberState identification number and state of issuanceDriver's license number and state of issuance
Date

MonthDayYear
I Understand that I am eligible to get Booster and If I am eligible I will provide my Medicare B card.
Should be Empty:

455 Hartford Rd , Manchester , CT - 06040 Phone 8606499946 COVID-19 Vaccine Appointment Form