Byrd-Watson Vaccine Clinic

Byrd-Watson Vaccine Clinic
We look forward to seeing you at your upcoming vaccine clinic! We will be administering Flu vaccines and/or the newest Covid booster. Please complete the following information as soon as possible. On the day of the clinic, please remember to wear short sleeves if possible.

Thank you,

Byrd-Watson Pharmacy
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Race:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email:
Please take photo of your insurance card.
If photo not available, please enter the following information from your prescription insurance card:
Rx BIN:
Rx PCN:
Cardholder ID:
Rx Group:
Please select which services you are requesting on the day of your clinic: (select up to 2 options)*

Flu VaccineCovid-19 Booster
Should be Empty: