Vaccine Sign up & Consent Form (all but Covid-19)

Family Pharmacy Vaccine(s) Signup Form
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender *

Female Male Prefer not to answer Other
Race *

African American Native American Asian White Native Hawaiian/ Other Pacific Islander Prefer not to answer Other
Ethnicity: *

Hispanic or Latino Non-Hispanic/Latino Unknown Prefer not to answer Other
Primary Doctor Name

First Name Last Name
I would like to get the following vaccine(s)-check all that apply: *

Influenza Vaccine (if under 65) High Dose Influenza Vaccine (if over 65) Prevnar 15 (followed in yr by Pneumovax 23) Prevnar 20 (single dose) Pneumovax 23(given 1 yr from Prevnar 13 or 15) Shingrix (shingles)-1st Dose Shingrix (shingles)-2nd Dose given 2-6 Months after initial dose Tdap
Insurance Information *

Commercial Medicare Uninsured
Insurance Company Name
Commercial Insurance Info

Member ID Number Group Number RX Bin Number PCN
Medicare Information

Medicare Number Part A Date Part B Date
Insured Patients

I authorize the pharmacy to bill my insurance on my behalf for the immunization.
Uninsured Patients

I do not have any insurance, including but not limited to Medicare, Medicaid or any other private or government-funded health benefit plan. I understand I will pay for the selected vaccine prior to getting vaccinated in the pharmacy.

Family Pharmacy Vaccine(s) Signup Form