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

Family Pharmacy Vaccine(s) Signup Form
Patient Name *

First NameLast Name
Date of Birth*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

FemaleMalePrefer not to answerOther
Race*

African AmericanNative AmericanAsianWhiteNative Hawaiian/ Other Pacific IslanderPrefer not to answerOther
Ethnicity:*

Hispanic or LatinoNon-Hispanic/LatinoUnknownPrefer not to answerOther
Primary Doctor Name

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

Influenza Vaccine (under 65)High Dose Influenza Vaccine (if over 65)COVID-19 Vaccine (Moderna-"Spikevax" for 12 years old and older)Prevnar 20 (Pneumonia-single dose)Shingrix (shingles)-1st Dose (50 yrs and older)Shingrix (shingles)-2nd Dose given 2-6 Months after initial doseTdap (Adacel)RSV Vaccine (Abrysvo) for 75 yrs and older)(60 to 74 yrs old may be eligible with certain medical conditions. Call to see if your eligible) -[please don't schedule for same day appointment]
Insurance Information*

CommercialMedicareUninsured
Insurance Company Name
Commercial Insurance Info

Member ID NumberGroup NumberRX Bin NumberPCN
Medicare Information

Medicare NumberPart A DatePart 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