• COVID-19 Vaccine  Information and Consent Form

    COVID-19 Vaccine Information and Consent Form

    * Please fill out the required details below
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    BIVALENT BOOSTER VACCINES:

    Pfizer & Moderna

     

    ARE AVAILABLE

    MONDAY-FRIDAY

    NO APPOINTMENT NECESSARY

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    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  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 INDIVIDUALS WHO ARE 18 YEARS OF AGE AND OLDER

    PFIZER is available for ages 5 and older

     

  • Section I. Personal Information

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  • Section II. Questionnaire for Immunization

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  • 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.

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  • INSURANCE INFORMATION:

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  • 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*** 

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