Xprs Rx Pharmacy - Vaccine Scheduler

Vaccine Scheduler

Select your vaccine below, fill out the requested information and schedule a time for your appointment. Questions? Call us: (424) 297-7779
Before we schedule your vaccine(s)

For the safety of other customers and our employees, let's first get these familiar questions out of the way. Please answer this brief COVID-19 questionnaire for the person being scheduled.
Do you currently or have you in the past 14 days, had a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?*

YesNo
Have you tested positive for COVID-19 within the last 14 days?*

YesNo
Vaccines Available*

Hepatitis-A (Hep-A)Hepatitis-B. (Hep-B)Diphtheria, tetanus & acellular pertussis (DTaP)Tetanus, diphtheria & acellular pertussis (Tdap)ShinglesPneumoniaMeningococcalMeningococcal BAREXY (RSV)
We want to help you spend less time in person, so let's take care of some details now. We'll ask for coverage information and may need insurance card(s) or voucher(s), if you have it.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Email*
example@example.com
Provide prescription insurance details

Enter patient prescription insurance details here and spend less time visiting us in person on vaccination day.

When adding your info to the form, please make sure your insurance details, including your Member ID and RxBin or Bin, are correct and exactly match your card before continuing.

All fields are required, unless marked optional.
Member ID*
Rx BIN or BIN*
Rx PCN *
Group ID
What is the patient relationship to the insurance cardholder?*

SelfSpouseChildOther
Please review and check ALL the boxes below*

Please bring your ID and insurance card with you to your appointment.Please arrive as close to your appointment time as possible to prevent traffic congestion.Please allow 30 minutes upon arrival. You will be required to remain on site for 15 minutes for observation. Additional instructions will be provided upon arrival.
Upload Prescription Insurance Card: *

Please upload your Prescription Insurance Card. If Medicare Part B - please include Supplemental Insurance, if applicable. *Take note that this is a required field. If the information on the card does not match this form, then the time of your appointment may take longer.
Cancelof
Patients younger than 18 years must have parental or guardian consent, unless patient is an emancipated minor.
Schedule a Vaccine Appointment
Notes for Pharmacy
Should be Empty: