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  • COVID-19 Bivalent (Omicron) Booster Vaccine Eligibility and Consent Form

  • This form is specific to determining if you are eligible for a COVID-19 Bivalent (Omicron) Booster Vaccine. You have indicated that you are not interested in receiving a COVID-19 Bivalent (Omicron) Booster Vaccine. Please make sure you have selected the correct form. If you have further questions or concerns please contact us at 270-547-2855. Thanks!

  • Based on your selected age, you are not eligible to receive a COVID-19 Bivalent (Omicron) Booster Vaccine at Save-Rite Drugs in Irvington. Please check back with us at a later date to see if the CDC has modified their guidelines to eligibility. If you have any questions you may contact us at 270-547-2855. Thanks!

  • COVID-19 Bivalent (Omicron) Booster Vaccine Eligibility and Consent Form

  • What was the date of your most recent COVID-19 vaccine? (Please look at your vaccine card to find your last date) Pick a Date*   

  • COVID-19 Bivalent (Omicron) Booster Vaccine Eligibility and Consent Form

  • At this time, based on your answers of either not completing a primary series or it being less than 2 months since your last dose of a COVID-19 vaccine, you do not qualify for a COVID-19 Bivalent (Omicron) Booster Vaccine. Please complete this form at a later date when you either qualify based on your answers to the previous questions or the CDC updates their guidance regarding who is eligible. If you have any questions or belive that you should be eligible, please contact us at 270-547-2855. Thanks!  

  • COVID-19 Bivalent (Omicron) Booster Vaccine Eligibility and Consent Form

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    Pick a Date

  • Do you have a history of any of the following medical conditions?
    Myocarditis or Pericarditis    *   
    An Immune-mediated syndrome defined by thrombosis and thrombocytopenia, such as heparin-induced thrombocytopenia      *   
    Guillain-Barre Syndrome      *   
    Multisystem Inflammatory Syndrome (MIS-C or MIS-A)      *   
    History of Thrombosis with Thrombocytopenia Syndrome (TTS)      *   
    History of COVID-19 disease within the past 3 months      *   

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  • Please bring a copy of your prescription insurance card or Medicare Part B (Red, White and Blue card) to your appointment. If you do not have prescription insurance you are still eligible to receive a Booster Vaccine dose.

    Also, please bring your COVID-19 vaccine card to your appointment. If you have lost your card, please call and notify the pharmacy in advance in order to avoid appointment delays. 

    After clicking the submit button below, you will be directed to schedule your appointment for your COVID-19 Booster vaccine. If you would also like to receive another vaccine during your same appointment, such as Flu or Pneumonia, you must fill out another eligibility and consent form for your other requested vaccine and you will schedule a 2nd appointment for that vaccine as well.

    You will be directed how to complete another eligibility and consent form for your 2nd vaccine when you finish scheduling your 1st vaccine. 

    If you have any questions please feel free to contact us at 270-547-2855. Thanks!

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    Pick a Date

  • This QR Code will take you to the required Emergency Use Authroization (EUA) Fact Sheet for the Pfizer COVID-19 vaccine that must be offered with each vaccine given. If you wish to receive a printed copy of this Fact Sheet, please inform us when you arrive at the pharmacy. Thanks!

                                                     

  • This QR Code will take you to the required Emergency Use Authroization (EUA) Fact Sheet for the Moderna COVID-19 vaccine that must be offered with each vaccine given. If you wish to receive a printed copy of this Fact Sheet, please inform us when you arrive at the pharmacy. Thanks!


                                   

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