• COVID-19 Vaccine Information and Consent Form

    * Please fill out the required details below
  •  

    2nd BOOSTER VACCINES:

    Pfizer & Moderna

    BOOSTER VACCINES

    ARE AVAILABLE

    MONDAY-FRIDAY

    NO APPOINTMENT NECESSARY

     

    PFIZER VACCINES FOR CHILDREN AGES 5 AND OLDER ARE NOW AVAILABLE MONDAY-FRIDAY

    NO APPOINTMENT NECESSARY

     

    VACCINE SCHEDULING PROCEDURE

    If you would like to make an appointment for a COVID-19 Vaccine, please fill the information below and we will contact you immediately with a same day or a next day appointment for your COVID-19 Vaccine.

    Walk-Ins Also Welcome

    Monday-Friday

    Hazle Drugs is administering the  following vaccines:                      

    • Moderna
    • Pfizer (Available for Ages 5 and Older
  •  MODERNA IS AVAILABLE TO THOSE INDVIDUALS WHO ARE 18 YEARS OF AGE AND OLDER.

    PFIZER vaccines are available for ages 5 and older

     

         

  • Section I. Personal Information

  •  /  /
    Pick a Date
  •  -  -
    Pick a Date
  • Section II. Questionnaire for Immunization

  •  
  • **Vaccine supply is limited.  Please keep your appointment when we contact you.  If you miss your appointment, no doses of vaccine will be held for you.**

  • Clear
  • I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.

  • Clear
  • Browse Files
    Cancel of
  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

     

    *** TO RECEIVE AN EMAIL CONFIRMATION OF YOUR FORM SUBMISSION PLEASE ENTER YOUR EMAIL ADDRESS IN THE BOX BELOW. THE EMAIL CONFIRMATION WILL BE FROM JOTFORM*** 

  • Should be Empty: