All Vaccine Form

Sept 15, 2025 update: - We have receive newest COVID Vaccine(s)

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We make it easy for you to keep up with routine immunizations because we want you, your family, and everyone in the community to be at their best. Even though an appointment is not "required", it’s preferred for more efficient service. Most vaccines are covered by majority insurance with as little as $0 Co-Pay.

This universal form will be utilized for age groups 5 and above so if you are coming together as a family you will need to fill out 1 form per person.

Clinic Location: 100 East Main St, Lititz PA 17543

What do I need to bring with me:

- Any and all insurance information

- A printed copy of the single page PDF of this form to for a more efficent process.

Consent, wavier, vaccine Information Sheet LINK

Select an appointment time: Please pick a day and time below (to see next month's appointments, click on the down arrow next to the current month) *If you selected multiple vaccines, they will be administered at the same appointment time --- if you are coming with a spouse or family member(s) select the closest appointment together & we will take you in together***

Select the primary vaccine you wish to receive. *

Select any secondary vaccine you wish to receive with the same appointment. You may get up to 3 vaccine at same time.

Email*

example@example.com

Name

First NameLast Name

Vaccine Recipient Physical Address*

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code

Date of Birth*

Gender*

MaleFemale

Vaccine Recipient Phone Number*

Allergies

Please answer "Yes" or "No" to the questions below concerning the patient's Medical History. The caregiver may fill this out on behalf of the patient. If unsure or you answer "Yes" to any of these and have concerns, please consult your doctor prior to receiving a vaccine. To save you time in person, we ask these questions now.*

	Yes	No
1. Are are feeling sick today? (Fever, cough, shortness of breath, sore throat, congestion or runny nose)
2. In the past 28 days, have you been diagnosed with COVID-19, exposed to someone COVID-19, or received any vaccine or a TB test?
3. Do you have any allergies to medications, foods (e.g. eggs), latex, a vaccine component (e.g thimerosal, polyethylene glycol,etc.) or a serious reaction to vaccine in past (swelling, trouble breathing, fainting or seizure?
4. During the past year, have you received a transfusion of blood or blood products, been given immune (gamma) globulin or an antiviral drug, or received COVID-19 antibody treatment?
5. Do you have a long-term health problem such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g., diabetes) anemia or other blood disorder?
6. Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, Crohn’s disease, herpes, or cold sores?
7. In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids, or anticancer drugs, or have you had radiation treatments?
8. For women: Are you pregnant or is there a chance you could become pregnant during the next month?
9. For TDap and adult TD: Do you have a cut, injury, puncture or open wound that prompted you to get a vaccine?

CONSENT & WAIVER: By clicking the box below, I am indicating my consent and agree my electronic signature is the legal equivalent of my manual signature on this Agreement. If I am signing on behalf of another individual (including a minor), I attest that I have the authority to do so. Please note that patients under 18 must have the consent of a parent or guardian. If I am receiving a COVID-19 vaccine dose, I attest I am eligible for that dose according to current recommendations from the CDC.*

I acknowledge & accept the waiver and consent

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):*

Date Signed *

Date

Which arm would you like to receive vaccine(s)

LeftRightOne in each arm

Insurance information: Please input the numbers/letters from your Prescription Insurance card, or bridge voucher, or if applicable, Medicare B Card, below. IF you have Medicare Part B through AETNA HMO, UNITED HEALTHCARE HMO (i.e. Verizon employees), or any other Part B, please put that card info below. You are looking at your prescription card if it has the letters RX on it otherwise, you are likely looking at your medical card. If your card does not have one of the below, please leave that field blank. If you do not have insurance, put in the last 4 of your SSN. After filling it out, hit "Next." Not providing this information now could delay your registration on-site.

2025 - Lititz Apothecary Vaccine appointment