Vaccine

We give Pfizer and Moderna vaccines. The Pfizer vaccine is approved for ages 12 and over. The Moderna vaccine is approved for ages 18 and over. We give both vaccines from 10am to 1PM and 2 PM to 5 PM Monday thru Friday. Due to overwhelming demand we are now accepting appointments. Thank you.

Patient’s Name *

First Name Last Name

Is this your first, second or third Covid vaccine?

If this is your 3RD vaccine (booster) do you attest to being moderately to severely immunosuppressed?

Are you the patient or the patient's guardian

Name of person filling out this form:

If you are the patient's guardian do you consent to the patient being vaccinated?

If the patient is between the ages of 12 to 17 years old they are eligible to receive the Pfizer vaccine. Please choose Pfizer below.

If you are 18 years old or over which vaccine would you prefer?

Date of birth *

Race *

Sex *

Address *

City *

State *

Zip Code *

Phone Number *

Social Security Number *

What is your email address?

Are you over 18 years of age?

Yes No

Medicare ID

IF YOU DO NOT HAVE YOUR MEDICARE ID, PLEASE USE YOUR SOCIAL.

If you are not a current customer you may upload your insurance card

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Are you allergic to SM-102PEG200? *

Have you ever had a serious allergic reaction to any other vaccine or injectable? *

Do you have Covid or are you recovering from Covid? *

Have you had any other immunizations within the last 14 days? *

If yes please list below:

Do you have a moderate or severe illness today? *

Have you received passive antibody therapy withing the last 90 days? *

Are you pregnant or breast feeding? *

Do you consent to wait 15 minutes after being immunized for observation? *

Patient or Guardian Signature (Insert name then sign in the store)

________________________________________________________

Appointment

Signature

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McCook's Pharmacy