Caligor Pharmacy COVID-19 Vaccine Appointments and Consent Form

Vaccine Appointments and Consent Form
**Pfizer COVID Vaccine is NOW AVAILABLE

If you have any questions please call us at 212-369-6000.
Vaccine Manufacturer*

COVID Vaccine (Pfizer)ABRYSVO (RSV Vaccine)Influenza Vaccine - Reg Dose (4-64 years)Influenza High Dose Vaccine (65 years+)Shingrix (Shingles Vaccine)Other (Pneumonia, Hepatitis A or B, TDAP, HPV)
Select an appointment time*
How many patients need to schedule a vaccine for this time?
Note: If you need to schedule an appointment at this time slot for two (2) or more people, complete the form for one (primary) person, and additional patients will be added when you arrive
Vaccine Recipient Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email*
example@example.com
Parent/Guardian/Surrogate
(if applicable, please print)
Emergency Contact Name*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*
Do you have any Allergies to Food or Medication*

YesNo
Please list all Allergies*
Please List All
Who is your Primary Care Provider and what is their phone number? (We will notify them of your vaccination) Type "NA" if you don't have one.*
Signature of Patient or Parent/Guardian/Surrogate*

Clear
Name of Signer

First NameLast Name
Relationship to Patient*
Date Signed*

MonthDayYear
Date
Insurance Information

Complete as much as possible
The COVID-19 vaccine is available to anyone no matter if insured or uninsured. Please check only one of the following. All other vaccines require insurance or payment out of pocket*

If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.If UNINSURED, you must check this box to attest that the the following information is true and accurate: I do not have any insurance, including but not limited to, Medicare, Medicaid, or any other private or government-funded benefit plan.
Primary Insurance Name
Primary Insurance ID#
Subscriber Name
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Relationship to Patient
Primary Insurance Address
Primary Insurance Group #
Primary Insurance Phone #
Please enter a valid phone number.
Secondary Insurance Name
Secondary Insurance ID #
Secondary Insurance Address
Secondary Insurance Group #
Secondary Insurance Phone #
Please enter a valid phone number.
Primary Care Provider Name
Primary Care Provider Phone Number
Please enter a valid phone number.
Clinic Office where Vaccine will be Administered
Should be Empty:

Vaccine Appointments and Consent Form

Insurance Information