• Tarrytown Pharmacy Vaccination Appointment

    Please read below carefully and fill out the form to the best of your knowledge.
  • Patient Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Appointment Scheduling

    Please select a date and time for your vaccination appointment. If you will be selecting multiple vaccines, they will be administered at the same appointment time.
  • Appointment: Please pick a day and time below (to see next month's appointments, click on the down arrow next to the current month)*

  • Click "Next" to Choose Vaccines

    Once you have filled out your Name, Date of Birth, and selected an appointment time, go to the next page to choose what vaccines the patient would like to receive.

  • Vaccine Selection

  • Please select which vaccines you would like to schedule an appointment for (Select ALL that apply):*

  • *Appointment Type Not Available Based on Age*

    • Flu and COVID-19 Vaccines
      • Flu and COVID-19 vaccines can be offered to patients 3 years and older under the federal PREP Act without a prescription because they currently are approved by the FDA and the CDC.  
    • Other immunizations besides Flu and COVID-19 

      • Ages 14 and older: We can vaccinate without a prescription per current Texas law. For patients less than 14, we can administer the vaccine with a prescription.

    Please call the pharmacy at 512-478-6419 if you have additional questions, and thank you for understanding!

  • Select which COVID-19 vaccine: Ages 12 to 64*
  • Select which COVID-19 vaccine: Ages 65 and up*
  • COVID-19 Vaccine Eligibility: Please Select One*
  • Underlying conditions that put patients at high risk for severe COVID-19 outcomes: Please select one. **The first option can be selected if the patient does not have a condition listed and still wants to receive the COVID-19 vaccine.*
  • Other Immunizations: Ages 14 to 17 (If you are looking for a vaccine not on this list, please call the pharmacy to check availability) *Prescription required for ages 3-13**
  • Other Immunizations: Ages 18 to 19 (If you are looking for a vaccine not on this list, please call the pharmacy to check availability)*
  • Other Immunizations Ages 19-25: (If you are looking for a vaccine not on this list, please call the pharmacy to check availability)*
  • Other Immunizations: Ages 26 to 45 (If you are looking for a vaccine not on this list, please call the pharmacy to check availability) *Prescription required for ages 3-13**
  • Other Immunizations: Ages 46 to 49 (If you are looking for a vaccine not on this list, please call the pharmacy to check availability) *Prescription required for ages 3-13**
  • Other Immunizations: Ages 50 to 59 (If you are looking for a vaccine not on this list, please call the pharmacy to check availability)*
  • Other Immunizations: Ages 60 and older (If you are looking for a vaccine not on this list, please call the pharmacy to check availability)*
  • Is this your first or second dose of Shingrix?*

  • Presumptive Evidence of Immunity for Measles

    If you were born before 1957, you are considered to have "presumptive evidence" of immunity for measles and likely do not need the M-M-R vaccine. By continuing to book the appointment, you are acknowledging that you understand and would like the vaccine anyway.

    Please call 512-478-6419 and speak with a pharmacist if you have any questions! 

  • Patient Demographic Information Continued

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  • Is the patient LESS than 18 years old, and/or UNABLE to provide medical consent for themselves?*

  • Because the patient is less than 18 years old, who is providing authorized consent for this vaccine?*. Please enter relationship to patient that allows for authorization of medical consent(parent, legal guardian, power of attorney) *

  • Patient Gender: (M: Male and F: Female)*
  • In which arm would you like to receive your shot? (Can be changed at appointment)*
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  • Format: 0000.

  • Patient Medical History

  • Enter Patient Medical History:*
    Rows

  • Patient Prescription Insurance

  • Does the patient have health insurance?*
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  • Appointment Reminder
     - -
    2 digit month, 2 digit day, 4 digit year
  • 2 days after appointment email
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Appointment:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Acknowledgement, Consent, and Signature

  • Acknowledgment, Consent, and Authorization

    By signing, I certify that I am the patient, the patient's parent or legal guardian, or otherwise legally authorized to consent on the patient's behalf, and I voluntarily consent to administration of the vaccine(s) selected above. I acknowledge that I have received or been given the opportunity to review the applicable Vaccine Information Statement (VIS), EUA Fact Sheet (when applicable), or other required educational materials. I have had the opportunity to ask questions and understand the benefits and potential risks of vaccination. I acknowledge receipt of Tarrytown Pharmacy's Notice of Privacy Practices. I authorize Tarrytown Pharmacy to submit claims to my insurance or other third-party payer, release information as permitted by law for payment and healthcare operations and receive payment for services provided. I understand that I may be responsible for charges not covered by my payer. I understand that immunization information may be reported to ImmTrac2 or other applicable immunization registries as permitted or required by law. I certify that the health information and screening responses I provided are complete and accurate to the best of my knowledge and that I have disclosed any allergies, medical conditions, medications, or previous vaccine reactions that may affect vaccination.

    By signing this consent, I acknowledge that:

    • Tarrytown Pharmacy, acting as a healthcare provider, has made information about the risks and benefits of COVID-19 vaccination available to me and has offered the opportunity to ask questions.
    • My decision to receive this vaccine is based on either (a) the presence of a risk factor, or (b) my own choice following shared clinical decision-making with a Tarrytown Pharmacy pharmacist.
    • I release and hold harmless Tarrytown Pharmacy, its pharmacists, staff, the ordering pharmacist, and the supervising physician from any and all liability arising from my election to receive this vaccination in accordance with FDA labeling and recognized immunization guidelines.
    • I have read and understood the acknowledgment letter provided above.
    • I declare that the information I have provided above is correct.
    • I am also interested in potentially getting email updates from Tarrytown Pharmacy. An email confirmation will be sent, and you can opt-in if you're interested in getting updates, otherwise just ignore the email.
    • I am giving my full consent to get the selected vaccine(s) of my own will.
    • I will show up on time for my appointment.
    • If I miss my appointment for any reason I will have to book a new appointment for a different day to reschedule. 
    • I also understand that if there are issues with insurance coverage, a lot of times the issue arises from the insurance company and not Tarrytown Pharmacy.
    • I have been provided with the current DSHS CDC Vaccine Information Statements.
    • I have been provided the current DSHS Vaccine Information Sheet for COVID vaccines
    • I have been provided with this list of vaccine components, contraindications, and precautions.
    • I have been provided with information about the CDC's V-safe After Vaccination Health Checker
    • I have been provided information on how to report an adverse reaction to a vaccine through VAERS.

     

  • Date of Form Completion*
     - -
    2 digit month, 2 digit day, 4 digit year
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