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 Name Middle Name Last Name
Vaccine Recipient Physical Address

Street Address

Street Address Line 2

City State Initials

Postal / Zip Code
Date of Birth *

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

MODERNA PFIZER JANSSEN
Have you received a dose of COVID-19 Vaccine ? If yes, Manufacturer for the first dose received .
Required if you selected "Yes" to #2
Date of first dose / FIRST BOOSTER

Month Day Year
Required if you selected "Yes" to #2
IS THIS YOUR BOOSTER SHOT

YES NO

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 Number State identification number and state of issuance Driver's license number and state of issuance
Date

Month Day Year
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