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

Family Pharmacy Vaccine(s) Signup Form
Age
Today's Date*

MonthDayYear
Patient Name *

First NameLast Name
Email*
example@example.com
Date of Birth

MonthDayYear
Date
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:

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]Influenza Vaccine (Ages 3-64)High Dose Flu Vaccine (Over 65 yrs old)
I would like to get the following vaccine:

Covid-19 Vaccine (Spikevax) 2025-2026 (OUT OF STOCK FOR 10/23)
I would like to get the updated 2025-2026 Covid-19 Vaccine by Moderna (Spikevax). Please select any one of the following if it applies to you. All choices after the 1st pertain to ages (12-64). In Maryland everyone who wants the Covid-19 Vaccines is eligible. By registering for the Covid-19 Vaccine, you are attesting that you have had the opportunity to ask questions that were answered to your satisfaction. (I understand the benefits and risks of the vaccine and consent to the vaccine administration.)

I'm 65 Years old or olderCancerCerebrovascular disease (stroke)Cystic FibrosisDementia or Neurological conditions (including Parkinson's Disease)Disabilities (developmental, intellectual, birth defects, cerebral palsy, spinal cord injuries, Down Syndrome, ADHD)Heart Condition (heart failure, CAD cardiomyopathies)Blood Disorders (sickle cell, thalassemia)HIV InfectionImmunocompromised states (cancer treatment, organ transplant, corticosteroids, primary immunodeficienciesMental health conditions (depression, schizophrenia)Overweight & Obesity (BMI >25, risk rises with BMI)Physical InactivityPregnancy and Post-partum (within 42 days)Smoking (current or former)Organ or stem cell transplantSubstance use disorders (alcohol, opioids, cocaine)Tuberculosis (TB)
Insurance Information*

CommercialMedicareUninsured
Insurance Company Name
Commercial Insurance Info

Member ID NumberGroup NumberRX Bin NumberPCN
Medicare Information

Medicare NumberPart A DatePart B Date
Please Upload Copy of your Insurance Card Here:

Cancelof
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