Vaccine Appointment Form

1

Are you a walk-in patient for a vaccine?* This field is required.Only choose respond YES if you are currently in the pharmacy during weekdays between 12pm-5pm

YESNO

2

276 Main St White Plains, NY 10601

914-607-3939

www.mysunshinepharmacy.com

See Pharmacy Staff for Walk-in Vaccine

Weekdays between 12pm-5pm

You're in luck. No need to register online. Please see a pharmacy team member to get your vaccine please make sure you have the following:

Medical and Prescription Card
Identification card
Best contact number for you

Uninsured looking for Covid Vaccine? Please make sure you sign up for Covid Bridge Access program HERE to get a voucher.

Present that voucher to the pharmacy

Vaccine Availability Information

Please read the information below

Vaccine Appointment Times
- Mon-Fri 9:30 AM to 5:00 PM
- Sat 9:30 AM to 1:00 PM
Vaccine Walk-in Times (Please note wait time for walk-in may be up to 20 minutes)
- Mon-Fri 12:00 PM to 5:00 PM

Vaccines Available (Last update: 9/5/2025 Covid-19 Vaccine Authorized by way of EO from NYS)
- Age 3 and Older: Please see the Child & Adolescent Vaccine Schedule Here
  - Flu Vaccine 2025-26 Season
  - Covid Vaccine 25-26 Season
- Age 12 and Older:
  - Flu Vaccine 2025-26 Season
  - Covid Vaccine 25-26 Season
- Age 18 and older: Please see the Adult Vaccine Schedule Here
- - Shingles Vaccine (Shingrix)
  - RSV
  - Pneumonia Vaccine (Prevnar 20, Prevnar 13 & Pneumovax 23)
  - Tdap/Td
  - Hepatitis A
  - Hepatitis B
  - HPV (Human Papillomavirus)
  - MMR
  - Varicella
  - Meningitis (Meningococcal ACWY and B)
  - Covid Vaccine 24-25 Season

3

Please select your vaccine appointment time* This field is required.

4

Patient Date of Birth* This field is required.Please be advised Covid Vaccine and Flu Vaccine age 3+

Date of Birth

5

Calculated Age

6

Are you registering for the Flu vaccine?* This field is required.

YESNO

7

Are you registering for the Covid Vaccine?* This field is required.

YESNO

8

Which Covid Vaccine would you like?* This field is required.Please note: We usually have both vaccines in stock but occasionally we may be out of stock of one and suggest the other. The CDC and FDA advise to take whichever is readily available as both are comprable in its effectiveness.

COVID-19 2025-26

9

Are you registering for the RSV vaccine?* This field is required.

YESNO

10

Are you interested in a vaccine that is NOT COVID, FLU or RSV* This field is required.

YESNO

11

Vaccine Availability Information

Please read the information below

Vaccine Appointment Times
- Mon-Fri 9:30 AM to 5:30 PM
- Sat9:30 AMM t1:30 PMPM
Vaccine Walk-in Times (Please note wait time for walk-in may be up to 20 minutes)
- Mon-Fri 12:00 PM to 5:00 PM

Vaccines Available (Last update: 9/5/2025 Covid-19 Vaccine Authorized by way of EO from NYS)
- Age 3 and Older: Please see the Child & Adolescent Vaccine Schedule Here
  - Flu Vaccine 2025-26 Season
  - Covid Vaccine 25-26 Season
- Age 12 and Older:
  - Flu Vaccine 2025-26 Season
  - Covid Vaccine (Pfizer and Moderna) 25-26 Season (9/5/2025 Authorized by way of EO from NYS)
- Age 18 and older: Please see the Adult Vaccine Schedule Here
- - Shingles Vaccine (Shingrix)
  - RSV
  - Pneumonia Vaccine (Prevnar 20, Prevnar 13 & Pneumovax 23)
  - Tdap/Td
  - Hepatitis A
  - Hepatitis B
  - HPV (Human Papillomavirus)
  - MMR
  - Varicella
  - Meningitis (Meningococcal ACWY and B)
  - Covid-19 Vaccine (Pfizer and Moderna) 23-24 Season

12

Vaccine Recipient Name (Patient)* This field is required.

First Name

Last Name

13

Gender* This field is required.

Male

Female

Unspecified

14

Today's Date

Date

15

Patient Address* This field is required.

Street Address

City

State

Zip Code

Country

16

Does the patient have an apartment number?* This field is required.

YESNO

17

Please provide the Apartment number below* This field is required.

18

Patient's Cell Phone Number* This field is required.

Please enter a valid phone number.

19

Please provide an email address for the patientThis will be used to send you your Appointment Confirmation

example@example.com

Confirm Email

21

Do you have insurance?* This field is required.

YESNO

22

I agree to provide my medical AND prescription insurance card to a pharmacy staff member at the time I arrive for my vaccine.* This field is required.

YESNO

23

I do not have insurance and I agree to pay for the vaccine(s) or provide a voucher from the Covid Bridge Access Program (link provided in confirmation email).* This field is required.

YESNO

24

Please review the Consent information below:

I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Sunshine Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Sunshine Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required.
I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

Vaccine Information Statements(VIS): Please click below for the VIS for the vaccine patient is receiving

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Please Complete Patient or Parent/Guardian/Authorized Caregiver Signature* This field is required.If patient under the age 18 or are a Caregiver of the patient please sign for patient

Clear

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We’d love your feedback—was our scheduling tool simple and convenient for you?

YESNO

27

At Sunshine Pharmacy, we offer free delivery, personalized medication packaging, vaccine services, and one-on-one support. Would you be interested in making us your regular pharmacy?

Yes

No

Yes, but my insurance says I cannot use Sunshine