Parkway 2024

Parkway Pharmacy

FALL VACCINES - 2024
DID YOU KNOW WE OFFER AT HOME VACCINES FOR FAMILY AND FRIENDS THAT CANNOT MAKE IT TO US? ASK A TEAM MEMBER FOR MORE INFO!

We will also come to your place of WORK, SCHOOLS or your CHURCH for an on-site Vaccine clinic to help everyone stay protected this year!
Personal Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemale
Medical History

Type a question

	Yes	No	Not sure
Do you have allergies to latex, food, medications, or vaccine components? (such as eggs, thimerosal, gelatin, neomycin, phenol, or bovine protein)?
Did you ever experience any serious reaction after getting a vaccine?
In the past year, did you receive a transfusion of blood or blood products, or get injected immune (gamma) globulin or any antiviral drug?
Did you have any brain or other nervous system disorders?
Are your pregnant or planning to get pregnant or your partner is planning to get pregnant?

Do you have any of the followings? (select all that apply)

Lung diseaseHeart diseaseAsthmaKidney DiseaseDiabetesAnemiaBlood disorderNoneOther
Do you have an immunocompromised condition? (select all that apply)

CancerLeukemiaLymphomaHIV/AIDSTransplantAspleniaCSF leakCochlear implantNoneOther
Do you have any of the followings?

CoughColdFeverShortness of breathSore throatLoss of smell/tasteAbdominal pain/diarrheaAbnormal bruising or bleeding/eye redness
Which Vaccine(s) are you getting today?*

Moderna Booster (recomended)Pfizer BoosterInfluenza VaccineRSV VaccineShingles VaccinePneumonia Vaccine
Has it been at least 4 months since your last Covid booster?

YesNo
Has the person to be vaccinated ever had Guillain-Barre syndrome less than 6 weeks after vaccination, uncontrolled seizures or any unstable neurological disorder?

Yes - I need to speak to the pharmacist or nurseNo
Insurance Information
Do you have Medicare?*

YesNo
Please upload a picture of your Prescription Insurance card here

Cancelof
Medicare Information

Medicare NumberPart A DatePart B Date
Commercial Insurance

BIN NumberPCN NumberGroup NumberID Number
ONLY FOR MEDICARE RECIPIENTS - WE CAN COME TO YOU AND DO YOUR VACCINE IN YOUR HOME ALMOST ANY DAY OF THE WEEK. IF YOU WOULD LIKE US TO COME TO YOU, PLEASE SELECT IN MY HOME AND SOMEONE WILL REACH OUT TO YOU AND CONFIRM A DATE AND TIME. YOU MUST HAVE A CONFIRMATION CALL FIRST!

I would like Parkway Pharmacy to come to me, I am a Medicare recipient!Getting my vaccine in the pharmacy
Appointment
We would love to be your everyday pharmacy for all of your prescription needs. Please consider switching your refills over to us, the pharmacy you already know and trust!
Would you like to transfer your Rx's to us? We will do all the work for you! All you have to do is call us when you need a refill! We offer free same day delivery!

Yes!No thanks, I LOVE CVS so muchI already use another Independent
If you would like to transfer your Rx's to us, Who is your current pharmacy
Today's Date*

MonthDayYear
Date
By signing this form, I hereby accept that I have read and understood the acknowledgment letter provided above. I declare that the information I have provided above is correct. I am giving my full consent to get vaccinated of my own will.
Signature*

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Parkway Pharmacy

Personal Information

Medical History

Insurance Information