Lake Hills Pharmacy 2024 - Vaccine Scheduler

  • Lake Hills Pharmacy - Vaccine Scheduler

    Please read below carefully and fill out the form to the best of your knowledge.
  • Please select which vaccines you would like to schedule an appointment for (Select ALL that apply):*
  • Select which FLU SHOT best applies:*
  • Other Immunizations (If you are looking for a vaccine not on this list, please call the pharmacy to check availability) *Prescription required for ages 3-13**
  • Please select the date of your last Vaccine Dose (if applicable)
     - -

  • Appointment Scheduling

    Please select a date and time for your vaccination appointment. If you selected multiple vaccines, they will be administered at the same appointment time.
  • Appointment: Please pick a day and time below (to see next month's appointments, click on the down arrow next to the current month)*

  • Patient Demographic Information

  • Patient Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Is the patient LESS than 18 years old, and/or UNABLE to provide medical consent for themselves?*

  • Because the patient is less than 18 years old, who is providing authorized consent for this vaccine?*
    Please enter relationship to patient that allows for authorization of medical consent(parent, legal guardian, power of attorney)*

  • Patient Gender: (M: Male and F: Female)*
  • In which arm would you like to receive your shot? (Can be changed at appointment)*

  • Patient Medical History

  • Rows

  • Patient Prescription & Medical Insurance

  • Does the patient have health insurance?*
  • If you answered YES to the question above, please select which type of insurance you have: (Select All That Apply)*
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  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Should be Empty: