Neighborhood Pharmacy Vaccine Scheduling Form
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  • Welcome to Neighborhood Pharmacy's Vaccine Scheduling Form

    To ensure a smooth and efficient process, please have your insurance card (if any) handy while completing this form. This will help us accurately bill your pharmacy benefits and provide you with the best possible service.

  • Vaccine Selection and Personal Information

    Please select the type of vaccine you wish to receive and provide your personal information below.
  • *
  •  - -
  • Gender*
  • Format: (000) 000-0000.

  • Payment

    Vaccines may be billed to your pharmacy benefits. For questions about insurance coverage, please contact your insurance plan directly.
  • Choose a payment method*

  • Insurance Card Information

    Please input each of the following for your insurance card
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  • Vaccine Registration

    For Patients: The following questions will help us determine which vaccines you may be given today. If you answer "Yes" to any question it does not necessarily mean you should not be vaccinated today. It just means additional questions may be asked. If a question is not clear, please ask us to explain it.
  • Are you sick today?*
  • Do you have allergies to any of the following?*
  • Have you ever had a serious reaction after receiving a vaccination?*
  • Has any physician or healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?*
  • Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (diabetes), anemia or other blood disorders?*
  • Do you have cancer, leukemia, HIV/AIDS, or any other immunological disorder? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohns disease, herpes, or cold sores?*
  • In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?*
  • Have you had a seizure, brain/other nervous system problem or Guillain Barre?*
  • During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin or an antiviral drug (including acyclovir, famciclovir, valacyclovir)?*
  • Have you received any vaccinations or TB skin test in the past 4 weeks?*
  • Do you have a history of fainting, particularly with vaccines?*
  • For women: Are you pregnant or is there a chance you could come become pregnant during the next month?*
  • For Shingles (Zoster) vaccine: Have you had a past reaction to gelatin or triple antibiotic ointment?*

  • Consent to Vaccination

    I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Neighborhood Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

  • I acknowledge that Neighborhood Pharmacy complies with HIPAA regulations and ensures the confidentiality of my information."

  • Pharmacy Use Only

    Do no complete the below questions
  • Administered By:
  • Vaccine Administered
  • Site Administrtion

  • Date and Time of Administration:   Pick a Date      

  • Lot Number      

  • Expiration Date   Pick a Date   

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