Joseph Pharmacy 2nd Bivalent COVID-19 Vaccine Appointment Form

Joseph Pharmacy 2ND(SECOND) Bivalent Covid-19 Vaccine Appointment Form
Requirements for Vaccination of 2ND(SECOND) Bivalent Booster Dose
At this time we are able to vaccinate 2ND(SECOND) BIVALENT Booster shots for Covid-19 for these populations only:

Those 65 YEARS OF AGE AND OLDER WHO HAVE HAD A BIVALENT COVID 19 VACCINE 4 MONTHS AGO OR LONGER

OR

THOSE MODERATELY OR SEVERELY IMMUNOCOMPROMISED WHO HAVE HAD A BIVALENT COVID-19 VACCINE 2 MONTHS AGO OR LONGER

*** An email address will be used to confirm your appointment. In the unlikely event that you are not on our appoinment list, we will ask you for your confirmation email as proof of registration. Those without proof may be asked to schedule an appointment for a later date.
Appointment - IF ALL DATES ARE GRAYED OUT, THAT MEANS NOTHING IS AVAILABLE AT THIS TIME*
ID (Driver's License or Passport) THIS QUESTION IS NOT REQUIRED, BUT IF YOU CAN SUBMIT THIS INFORMATION, PROCESSING YOUR SHOT WILL BE FASTER.

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Insurance

For the next section, if you have a red white and blue Medicare card, we prefer that.
Insurance (Front of the Card) THIS QUESTION IS NOT REQUIRED, BUT IF YOU CAN SUBMIT THIS INFORMATION, PROCESSING YOUR SHOT WILL BE FASTER.

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Insurance (Back of the Card) THIS QUESTION IS NOT REQUIRED, BUT IF YOU CAN SUBMIT THIS INFORMATION, PROCESSING YOUR SHOT WILL BE FASTER.

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Salutation
First Name*
Middle Initial
Last Name*
Suffix
Date of Birth*

MonthDayYear
Date
CellPhone
Primary Phone*
Please enter a valid phone number.
Primary Phone Type*

CellHome
Email *
example@example.com
Address*
AddressTwo
City*
State Code (NY for New York)*
ZIP*
CountyOfResidence
Questionnaire
Race*
What is your ethnicity?*
Gender?*
Language
Mother's Maiden Name (only required for those 18 AND YOUNGER)
Guardian
DriverLicenseState
DriverLicenseNumber
DrugAllergies
HealthConditions
PcpName
PcpPhone
PcpAddressOne
PcpAddressTwo
PcpCity
PcpStateCode
PcpZip
Employer
HealthcareWorker
SocialSecurityNumber
MedicareBeneficiaryIdentifier
InsuranceType
Insurance Info

For the next section, if you have the RED WHITE AND BLUE Medicare card, we want that instead.
RX BIN (on insurance card unless red white and blue card)
RX PCN (on insurance card unless red white and blue card)
RX Group (on insurance card unless red white and blue card)
ID Number (on insurance card) Write ‘Uninsured’ if no insurance*
Relationship on the card (if Uninsured, check 01 Self)*

01 Self02 Spouse03 Child04 Other
InsuranceEffectiveDate
InsuranceType2
RxBin2
RxPcn2
RxGroupID2
MemberID2
Relation2
InsuranceEffectiveDate2
PrescriberFirstName
PrescriberLastName
PrescriberNpi
WrittenDate
Which Covid-19 Shot did you prefer? You will be told the day of the appointment if we do not have your preferred vaccine and will be offered an alternative.*

Pfizer Bivalent (12 years of age and older)Moderna Bivalent (18 years of age and older)
Quantity
UnitOfMeasure
Refills
Directions
DispensedItemNDC
DispensedQuantity
DaysSupply
Lot
LotExpiration
PharmacistFirstName
PharmacistLastName
PharmacistNpi
DoseNumber
AdministrativeSite
AdministeredDate
AdministrationLocation
TpoCode
FundingSource
VaccineForChildEligibility
RouteOfAdministration
ReportToRegistry
By signing below, I'm attesting that I meet the criteria for a 2nd Bivalent Covid-19 vaccine, that is:

Those 65 YEARS OF AGE AND OLDER WHO HAVE HAD A BIVALENT COVID 19 VACCINE 4 MONTHS AGO OR LONGER

OR

THOSE MODERATELY OR SEVERELY IMMUNOCOMPROMISED WHO HAVE HAD A BIVALENT COVID-19 VACCINE 2 MONTHS AGO OR LONGER
Signature*

Clear
Should be Empty:

Joseph Pharmacy 2ND(SECOND) Bivalent Covid-19 Vaccine Appointment Form

Requirements for Vaccination of 2ND(SECOND) Bivalent Booster Dose

Insurance

Questionnaire

Insurance Info