• Immunization Questionnaire and Scheduling

  • We have High dose and Standard dose Flu Vaccines in stock. Also COVID-19 Vaccines and others are available at the same time.

    *For COVID: Must be 65+ OR a verified chronic condition to be eligible. A prescription from your provider is also acceptable.
  • Which vaccine(s) would you like to receive? (availability may vary by location)*
  • Image field 95
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Schedule an Appointment

  • Downtown Appointments*
  • Parkers Appointments*
  • Glenwood Appointments*
  • Elbow Lake Appointments*

  • Insurance Information

  • Would you like a call with vaccine pricing information?

  • Health Questionnaire

    Note: Your pharmacist will review your answers and discuss any effects that may have on your requested immunization.
  • Are you feeling sick today?*
  • Do you have allergies to medications, food or vaccine?*
  • Do you have a history of Guillain-Barre Syndrome?*
  • Have you ever had a serious reaction after receiving a vaccine?*
  • Are you currently be treated for a long-term health problem such as heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?*
  • Are you currently being treated for cancer, leukemia, AIDS, or any other immune system problem?*
  • Are you currently taking prednisone, cortisone, other steroids or anti-cancer medications, or have you had X-ray treatments?*
  • Have you ever fainted or felt dizzy after receiving an immunization?*
  • Have you had a seizure, brain or nerve problem?*
  • During the past year, have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin?*
  • Have you received any vaccinations in the past 4 weeks?*
  • Are you allergic to eggs?*
  • Are you allergic to latex?*

  • Consent

  • By signing this form, I acknowledge that I have received information with regard to the vaccine's risks and benefits. I have had the opportunity to ask questions and have received the answer to my satisfaction. I aknowledge, attest and consent to providing verification of eligibility and related higher risk conditions at the request of Trumm Drug.  I am giving my full consent and requesting for administration for vaccination.

  • Pharmacy Use Only

  • Pharmacy Notes:

  • Should be Empty: