Caligor Pharmacy COVID-19 Vaccine Appointments and Consent Form

Novavax Primary Series (dose 1 and 2) can ONLY be administered to patients who have NEVER had a previous Covid vaccine

Novavax Boosters can ONLY be administered to patients who have had a primary series AND NO FURTHER BOOSTERS

Vaccine Manufacturer*

Pfizer Covid Vaccine - Bivalent (Booster)Moderna Covid Vaccine - Bivalent (Booster)Novavax Covid Vaccine - Dose 1 or 2Influenza Vaccine - Reg Dose (4 years and older)Shingles Vaccine (Shingrix)Novavax Covid Vaccine - (Booster)TDAP Vaccine

**9/19/22 - Moderna Bivalent Booster currently unavailable. Check back for updates/availability

Influenza High-Dose (Ages 65+) expected to be available mid-October. Check back for updates

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*

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

Signature of Patient or Parent/Guardian/Surrogate*

Clear

Name of Signer

First NameLast Name

Relationship to Patient*

Date Signed*

Date

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.

Please Upload Pharmacy Rx (Prescription) Insurance Card*

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If Uninsured, please upload driver's license or other ID

Primary Insurance Name

Primary Insurance ID#

Subscriber Name

Subscriber Date of Birth

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

Vaccine Appointments and Consent Form

Insurance Information