Vaccination Consent Form
By signing up for vaccination at Alan's Pharmacy, you agree that you will fill out the appropriate pre-vaccination forms at the pharmacy before vaccination and will inform the pharmacy if you unable to make it to your appointment time.
Select an appointment time
*
Vaccine Recipient Name
*
First Name
Middle Name
Last Name
Vaccine Recipient Physical Address
*
Street Address
Street Address Line 2
City
State Initials
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Vaccine Recipient Phone Number
*
Mother's Maiden Name
*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
*
Relationship to Emergency Contact
*
Phone Number of Emergency Contact
*
What Vaccinations are you requesting (Max of two vaccinations per visit)
Flu Vaccine
High Dose Flu Vaccine (>65 yrs)
Pneumonia
RSV
COVID-19 (when available)
Shingles (Shingrix)
TDap (Tetanus, Diptheria, Pertusis)
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Clear
Submit Consent Form (required)
Should be Empty: