Immunization Appointments at Tarrytown Pharmacy Logo

  • Tarrytown Pharmacy Vaccination Appointment

    Please read below carefully and fill out the form to the best of your knowledge.
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  • 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.

  • 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

  • *Appointment Type Not Available Based on Age*

    This patient is less than 14 and is requesting a vaccine other than Flu, which currently requires a prescription according to Texas state law.

    To continue with this appointment booking, please make sure that only the “Flu Shot” option is selected.

    • COVID-19 Vaccines

      • Ages 3–13: Pharmacies can currently give the vaccine only with a prescription from your child’s healthcare provider.

        • If you would like for your child to receive a COVID vaccine, Tarrytown Pharmacy can still administer the vaccine but would need a prescription from a provider. Or we could provide the vaccine without a prescription once the CDC votes September 18th/19th.

      • CDC Review Coming Soon: The CDC will meet on September 18–19 to review FDA recommendations. If approved, pharmacies will then be able to administer the vaccine to children ages 3 and older without a prescription.

      • Ages 14 and older: We can vaccinate without a prescription today, per Texas law. 

    • Flu vaccines (2025-2026 season) can still be offered to patients 3 years and older under the federal PREP Act, because they currently are approved by the FDA and the CDC.

    Please call the pharmacy if you have additional questions, and thank you for understanding.

    512-478-6419


    Thank you! – Tarrytown Pharmacy

  • 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! 

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  • Patient Demographic Information Continued

  • 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 Medical History

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  • Potential Serious Vaccine Allergy Alert:

    You have indicated that you are allergic to a common vaccine component that may be a contraindication or precaution to getting certain vaccines. For your safety, please call the pharmacy and speak with a pharmacist for more information about specific vaccine allergen components, if the vaccine you're looking would be safe to recieve, and next steps. Thank you for working with us to help keep our patients safe!

    Pharmacy Phone Line: 512-478-6419 -  Option: 4

  • Patient Prescription Insurance

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  • Emergency Contact Information

  • Acknowledgement, Consent, and Signature

  • Section IV. Signatures

    By signing this form I hereby give my consent to Tarrytown Pharmacy to administer the vaccine(s) I have requested. I certify that:

    I am (i) the patient and at least 18 years of age; (ii) the parent or guardian of the minor patient; or (iii) the legal guardian of the patient; or (iv) a person authorized under the law of another state or a court order to consent for the child OR
    The persons identified under (ii), (iii), or (iv) in the preceding sentence are unavailable and I have authority to consent to the immunization of the child because I am a (i) grandparent; (ii) adult brother or sister; (iii) adult aunt or uncle; (iv) stepparent; or (v) another adult who has actual care, control, and possession of the child and has written authorization to consent for the child from a parent, managing conservator, guardian, or other person who, under the law of another state or a court order, may consent for the child; additionally, I certify that I do not have knowledge of any express refusals or withdrawn authorizations of consent and have not been told not to give consent for the child.  
    I understand that any Protected Health Information (PHI) I provide to Tarrytown Pharmacy will only be used or disclosed by Tarrytown Pharmacy in accordance with Tarrytown Pharmacy's Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices. By signing below I acknowledge receipt of such HIPAA Notices of Privacy Practices and consent to the uses and disclosures of PHI described therein. While Tarrytown Pharmacy reserves the right to not do so, I consent to Tarrytown Pharmacy reporting my immunization information to the State Immunization Registry. Should Tarrytown Pharmacy elect to report my immunization history to the Texas central immunization registry, ImmTrac, I further understand that my immunization information may be accessed by other health care providers, educators, public health, representatives, state agencies, and certain insurance payers. I further authorize Tarrytown Pharmacy to (1) release my medical or other information to my healthcare professionals, Medicare, Medicaid, or other third-party payer as necessary to effectuate care or payment or otherwise, (2) submit a claim to my insurer for the below requested items and services, and (3) request payment of authorized benefits be made on my behalf to Tarrytown Pharmacy with respect to the below requested items and services.

    NOT A SUBSTITUTE FOR A PHYSICIAN

    I understand that Tarrytown Pharmacy representatives are not physicians trained to diagnose and treat medical problems. I acknowledge that the administration of Services does not constitute and should not be interpreted as medical advice or opinions substituting for the advice of a physician. I understand that the administration of Services does not create a doctor patient relationship between myself and Tarrytown Pharmacy. I agree to consult a physician if I require medical advice or services at any time.

    RELEASE, IMDEMNITY AND DISCLAIMER

    I understand that it is not possible to predict all possible effects or complications associated with receiving vaccines, including the novel COVID-19 vaccines. I understand the risks and benefits associated with novel vaccine(s) and elect to receive a COVID-19 vaccine. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. I additionally acknowledge that I have received a copy of the Tarrytown Pharmacy notice of privacy. Further, I acknowledge that I have been advised to remain near the vaccination location for approximately 15 minutes after administration for observation by the administering health care provider. I understand that in the course of the requested vaccine administration, a Tarrytown Pharmacy representative could possibly be exposed to my blood or bodily fluids. In such event, I agree to review and execute the "Tarrytown Pharmacy Post-exposure Consent for Testing" form.

    On behalf of myself, my heirs, and personal representatives, I further hereby WAIVE, RELEASE, and AGREE TO ENDEMNIFY, DEFEND, AND HOLD HARMLESS (including costs and attorney's fees) Tarrytown Pharmacy, its staff, agents, employees, and corporate affiliates from any and all liabilities or claims whether known or unknown arising out of, in connections with, or in any way related to the administration of vaccine(s) and related services, even should such damages or losses result from Tarrytown Pharmacy's negligence.

    I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.

    • 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 CDC Vaccine Information Statements.
    • 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.

     

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