COVID-19 2024-2025 Vaccine Eligibility and Consent Form Logo
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  • COVID-19 2024-2025 Vaccine Eligibility and Consent Form

  • This form is specific to determining if you are eligible for a COVID-19 Vaccine. You have indicated that you are not interested in receiving a COVID-19 Vaccine. Please make sure you have selected the correct form. If you have further questions or concerns please contact us at 270-547-2855. Thanks!

  • Based on your selected age, you are not eligible to receive a COVID-19 Vaccine at Save-Rite Drugs in Irvington as we do not currently stock the COVID-19 vaccine for children aged 6 months to 11 years. If you have any questions you may contact us at 270-547-2855. Thanks!

  • COVID-19 2024-2025 Vaccine Eligibility and Consent Form

  • COVID-19 2024-2025 Vaccine Eligibility and Consent Form

  • At this time, based on your answer of it being less than 2 months since your last dose of a COVID-19 vaccine, you do not qualify for the COVID-19 Vaccine. Please complete this form at a later date when you either qualify based on your answers to the previous questions or the CDC updates their guidance regarding who is eligible. If you have any questions or belive that you should be eligible, please contact us at 270-547-2855. Thanks!  

  • COVID-19 2024-2025 Vaccine Eligibility and Consent Form

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  • Do you have a history of any of the following medical conditions?
    Myocarditis or Pericarditis    *   
    An Immune-mediated syndrome defined by thrombosis and thrombocytopenia, such as heparin-induced thrombocytopenia      *   
    Guillain-Barre Syndrome      *   
    Multisystem Inflammatory Syndrome (MIS-C or MIS-A)      *   
    History of Thrombosis with Thrombocytopenia Syndrome (TTS)      *   
    History of COVID-19 disease within the past 3 months      *   

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  • Please bring a copy of your prescription insurance card and/or Medicare Part B (Red, White and Blue card) to your appointment. If you do not have prescription insurance you are still eligible to receive a COVID-19 Vaccine dose.

    After clicking the submit button below, you will be directed to schedule your appointment for your COVID-19 Vaccine. If you would also like to receive another vaccine during your same appointment, such as Flu, you must fill out another eligibility and consent form for your other requested vaccine and you will schedule a 2nd appointment for that vaccine as well.

    You will be directed how to complete another eligibility and consent form for your 2nd vaccine when you finish scheduling your 1st vaccine. 

    If you have any questions please feel free to contact us at 270-547-2855. Thanks!

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  • This QR Code will take you to the required Vaccine Information Sheet for the Pfizer Comirnaty COVID-19 vaccine that must be offered with each vaccine given. If you wish to receive a printed copy of this VIS, please inform us when you arrive at the pharmacy. Thanks!

                                                          
                                   

  • This QR Code will take you to the required Vaccine Information Sheet (VIS) for the Moderna Spikevax COVID-19 vaccine that must be offered with each vaccine given. If you wish to receive a printed copy of this VIS, please inform us when you arrive at the pharmacy. Thanks!

                                                       
                                   

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