Gibbs Pharmacy Vaccination Appointment
**COVID-19 Vaccines: current FDA guidelines require individuals to be age 65+ or have other conditions that put them at increased risk for COVID-19 in order to be eligible for vaccination. We are not currently stocking doses for children under the age of 12. **
Which vaccine would you like to receive? You can only select one vaccine at a time. If you would like to receive more than one vaccine at your appointment, you will have to complete an appointment form for each vaccine.
*
Other immunization (Shingles, Tetanus (TDAP), Pneumonia, etc.)
Flu Shot
COVID-19 (65+ OR Individuals with Immunocompromising Conditions Only)
Which flu shot best applies to you?
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Flu shot for ages 3-64
Flu shot for ages 65 and older
Other Immunizations (If you are looking for a vaccine not on this list, please call the pharmacy to check availability)
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Shingrix / SHINGRIX (50 years and older or immunocompromised ages 19-64)
Pneumonia / PREVNAR-20 (65 years and older or immunocompromised ages 19-64)
TDAP (Tetanus, Diptheria, and Pertussis) / BOOSTRIX (ages 10 and older)
RSV / ABRYSVO (75 years and older or 60+ with certain conditions)
HPV (Human Papillomavirus) / GARDASIL (14 years and older)
Meningitis A, C, W, and Y / MENQUADFI (14 years and older)
MMR (Measles, Mumps, & Rubella) / M-M-R II (14 years and older)
Hepatitis A / VAQTA (18 years and older)
Hepatitis B / ENGERIX-B (18 years and older)
Rabies / RABAVERT (3 years and older)
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Patient Cell Number
PrimaryPhoneType
Appointment Scheduling
Please select a date and time for your vaccination appointment. If you would like to receive multiple vaccines, they will be given at the same time regardless of appointment times.
Appointment
*
Date
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Month
-
Day
Year
Date
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Patient Demographic Information
Salutation
Patient First Name
*
MiddleInitial
Patient Last Name
*
Suffix
Patient Date of Birth
*
CellPhone
Patient Phone Number
*
Please enter a valid phone number. Only enter the numbers no ( ) or dashes
PrimaryPhoneType
Patient Email
Patient Address
*
Street Address Line 2
City
*
State Code
*
(Ex: TN)
Zip Code
*
CountyOfResidence
Is the patient LESS than 18 years old, and/or UNABLE to provide medical consent for themselves?
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Yes
No
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):
*
In which arm would you like to receive your shot? (This can be changed at the appointment)
*
Left Arm
Right Arm
Patient Race
*
Please Select
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Patient Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Patient Gender (M: Male and F: Female)
*
M
F
Patient's Mother's Maiden Name
*
This is needed for official documentation
DriverLicenseState
DriverLicenseNumber
DrugAllergies
HealthConditions
PcpName
PcpPhone
PcpAddressOne
PcpAddressTwo
PcpCity
PcpStateCode
PcpZip
Employer
HealthcareWorker
SocialSecurityNumber
MedicareBeneficiaryIdentifier
Patient Prescription Insurance
Does the patient have health insurance?
*
YES, I DO have health insurance
NO, I do NOT have health insurance (uninsured)
If you answered YES to the question above, please select which type of insurance you have: (Select All That Apply)
*
I am an existing Gibbs Pharmacy patient and my insurance information is up to date in the system
Medicare Part A/B (Red, White, and Blue Card for patients 65 and older)
Prescription Insurance (Coverage for prescriptions at a pharmacy)
Medical Insurance (Coverage for Medical and Office visits)
Medicaid
Medicare Part B ID# (red, white, and blue card for patients over 65)
*if you are not over 65 or do not have part B, enter "n/a".
Rx BIN#
This information is found on your PRESCRIPTION insurance card.
Rx PCN
This information is found on your PRESCRIPTION insurance card.
Rx GROUP ID
This information is found on your PRESCRIPTION insurance card.
MEMBER ID#
This information is found on your PRESCRIPTION insurance card.
Upload a file of the patient's insurance card:
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InsuranceType
RxBin
RxPcn
RxGroupID
MemberID
Relation
InsuranceEffectiveDate
InsuranceType2
RxBin2
RxPcn2
RxGroupID2
MemberID2
Relation2
InsuranceEffectiveDate2
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PrescriberFirstName
PrescriberLastName
PrescriberNPI
WrittenDate!!
-
Month
-
Day
Year
Date
Origin
ItemNDC
Quantity
UnitofMeasurement
Refills
Directions
DispensedItemNDC
DispensedQuantity
DaysSupply
Lot
LotExpiration
PharmacistFirstName
PharmacistLastName
PharmacistNPI
DoseNumber
AdministrationSite
AdministrationLocation
AdministeredDate
TpoCode
FundingSource
VaccineForChildEligibility
RouteOfAdministration
ReportToRegistry
ModernaNDC
Pfizer Adult NDC
Pfizer Peds NDC
0.5 Quantity
0.3 Quantity
Moderna DispensedItemNDC
Pfizer Dispensed NDC
Pfizer Peds Dispensed NDC
0.5 Dispensed Quantity
0.2 ML Quantity
0.3 Dispensed Quantity
Fluad NDC
FlucelvaxNDC
ABRYSVONDC
MMR NDC
RABAVERT NDC
SHINGRIX NDC
mENQUADFI NDC
VAQTA NDC
GARDASILNDC
ENGERIXBNDC
BOOSTRIXNDC
PREVNAR20NDC
1QUANTITY
EA UNIT
ML UNIT
Acknowledgement
By signing this document, I acknowledge that the previous questions have been answered to the best of my ability, and I give Gibbs Pharmacy permission to bill my insurance for the scheduled vaccine.
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