COVID 19 Immunization Appointment

We are following state and federal guidelines to distribute the vaccine. As soon as we start receiving vaccine, the appointment scheduler will be activated and you will be able to set up an appointment to receive the vaccine. Please do not contact the pharmacy to schedule an appointment.
COVID 19 Immunization Appointment

To schedule an appointment, please fill out the information below. Appointments are required to receive COVID Vaccination. If you schedule an appointment, please plan to keep that appointment. We do not want to waste vaccine. If you cancel your appointment and we cannot find someone to take you place that vaccine has to be wasted. Once we receive your appointment request, we will contact you to confirm your appointment one to three days before the date you chose. There is not a charge for the COVID -19 vaccine, but the pharmacy will bill your insurance a vaccine administration fee. BRING YOUR INSURANCE INFORMATION WITH YOU. WE WILL ONLY ATTEMPT TO CONTACT YOU TWICE TO CONFIRM YOUR APPOINTMENT. IF YOU MISS OUR CONFIRMATION CALLS, YOU WILL NEED TO RESCHEDULE. We will only be administering the Johnson and Johnson COVID-19 Vaccine. Please do not call the pharmacy to schedule an appointment or verify vaccine availability.
Please select an appointment date (If you cannot pick a date and time, there are no appointments available)*
Contact Information
First name*
Last name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a current Patient at HealthSmart?*
Date Of Birth*

MonthDayYear
Contact Phone Number*
Email address*
List Any Allergies You Have (If no allergies enter None)*
Appointment Details
Best method for contacting you?*
Insurance Information*
Enter Your Insurance ID Number
Enter Your Insurance Group Number
COVID 19 Prevaccination Checklist

Must be completed when scheduling appointment
Are you feeling Sick today?*
Have you ever received a dose of COVID 19 vaccine?*
If you have had a COVID-19 vaccine, which product did you receive?*
Have you ever had an allergic reaction to:
A previous dose of COVID-19 vaccinePolysorbatePolyethylene glycol (PEG)A MedicationAnother Vaccine (Flu, Pneumonia, Shingles, Tetanus)Any foodsEnvironment (Pets, bees, ants)None
Have you received any other vaccines in the last 14 days?*
Have you ever tested positive for COVID-19?*
If you have tested positive for COVID-19, what date did you have a positive test?
Enter mm/dd/yyyy
Have you received passive antibody therapy for COVID-19?
Do you have weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?*
Do you have a bleeding disorder or are you taking blood thinner?*
Are you pregnant or breastfeeding?*
Are you a healthcare worker?*
Have you had Guillian-Barre syndrome?*
If yes, a doctor order will be required before we can give you any vaccination.
You will be asked to verify this information again when you arrive for your appointment. Be expected to stay at the pharmacy for 15 to 30 minutes after your vaccination. If you are more than 15 minutes late for your appointment, you may be required to reschedule.
Please verify that you are human*
By submitting this form, I understand the benefits and risks of the vaccination as described in the Emergency Use Authorization (EUA) and/or CDC Vaccine Information Statement (VIS), which can be found at the following web address. https://www.cdc.gov/vaccines/covid-19/eua/janssen.html. I request the vaccine be given to me and I am authorized to sign this Consent and Release.
Should be Empty:

We are following state and federal guidelines to distribute the vaccine. As soon as we start receiving vaccine, the appointment scheduler will be activated and you will be able to set up an appointment to receive the vaccine. Please do not contact the pharmacy to schedule an appointment.

COVID 19 Immunization Appointment

COVID 19 Prevaccination Checklist