COVID Vaccine Consent Form - MediLink RxCare

VACCINE APPOINTMENT REGISTRATION AND SCHEDULER
PLEASE SELECT THE VACCINE YOU WOULD LIKE TO RECEIVE BELOW

**SUBJECT TO AVAILABILITY**

WE OFFER THE FOLLOWING VACCINES:

Flu, COVID-19, Shingles, RSV, TDAP, Pneumonia

We have a very limited inventory of COVID-19 vaccines. Your appointment is subject to availability.

Please call to check availability of any vaccines not listed here.

PLEASE NOTE: CHILDREN MUST BE OVER 30 LBS TO RECEIVE VACCINES AT MEDILINK RXCARE. PLEASE CALL TO DETERMINE IF YOUR CHILD IS ELIGIBLE TO RECEIVE A VACCINE AT MEDILINK RXCARE.

Your vaccine appointment will be at:

MediLink RxCare

44 South White Horse Pike

Hammonton, New Jersey 08037

If you have remaining questions, please call us at (609) 956-1900

TO SCHEDULE A VACCINE AT OUR VOORHEES LOCATION, PLEASE CALL (856) 566-4300.
Section I. Personal Information
Name of Person to Receive Vaccine:*

First NameMlLast Name
Which vaccine do you wish to receive? PLEASE NOTE THIS IS SUBJECT TO AVAILABILITY AND MAY CHANGE.*

FluFlu High Dose (ages 65+)COVID-19 (ages 12+)RSV (ages 65+)ShinglesTDAPPneumonia
I am scheduling on behalf of:

MyselfMy childA person for whom I am Legal Guardian or Power of Attorney
Date of Birth:*

MonthDayYear
Phone Number:*
Email
example@example.com
Address:*

Street Address Line 2
Gender:*

FemaleMaleOtherUnknownNon-Binary
Do you have any allergies?
Section II. Appointment Scheduler
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. Additionally, due to vaccine requirements, we may call you to see if you can come earlier, later or to a nearby location. If you miss an appointment, no doses will be held to guarantee your dose.**
Please pick a day and time for your vaccination*
Section III. Insurance Information
Who is your health insurance provider? If uninsured, type "uninsured."
Please type your health insurance or Medicare ID number. If uninsured, type "uninsured." If you have Medicare, please type your Medicare ID number found on your "red, white and blue" card.
Insurance*

I authorize the pharmacy to bill my insurance, if I have insurance, on my behalf for the immunization and for administration of the immunization. I understand that I will be responsible for any costs not covered by insurance.
Vaccination Consent*

I understand the benefits and risks of the vaccine that I am choosing to receive. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor or ward for who I legally represent that I am authorized to sign this Consent and Release.
I understand that the pharmacy cannot guarantee that a vaccine dose will be available on the date and time that I scheduled my appointment.

Our staff will be in contact should changes need to be made.

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.
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VACCINE APPOINTMENT REGISTRATION AND SCHEDULER