Lake Hills Pharmacy 2024 - Vaccine Scheduler

Patient Name*

PrefixFirst NameLast Name

Patient Date of Birth*

Date

Patient Email*

example@example.com

Patient Cell Phone Number: (Please double check for accuracy)*

Please enter a valid phone number.

Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the patient LESS than 18 years old, and/or UNABLE to provide medical consent for themselves?*

YesNo

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

Patient Gender: (M: Male and F: Female)*

MF

In which arm would you like to receive your shot? (Can be changed at appointment)*

Left ArmRight Arm

Patient Ethnicity*

Patient Race:*

What COUNTY does patient live in? (Ex. Travis, Hays, Williamson, etc)*

Enter Patient Medical History:*

	Yes	No	Don't know
Have you ever experienced a serious reaction after getting a vaccine?
Do you have allergies to medication, food, a vaccine component, or latex?
Do you have cancer, leukemia, HIV/AIDS, or other immune system problems, OR have you taken medications in the past 3 months that affect your immune system?
During the past year have you received a transfusion of blood, blood products, immune (gamma) globulin, or an antiviral drug?
For women: Are you currently pregnant or breastfeeding?
Have you received any vaccinations in the past 4 weeks?

If you answered "yes" to any of the questions above, please explain here:

Does the patient have health insurance?*

YES, I DO have medical or prescription insuranceNO, I do NOT have medical or pharmacy insurance (uninsured)

If you answered YES to the question above, please select which type of insurance you have: (Select All That Apply)*

I am an existing Lake Hills Pharmacy patient and my insurance is up to date in the systemMedicare Part A/B (Red, White, & Blue Card for patients over the age 65)Prescription Insurance (Coverage for medications at a pharmacy)Medical Insurance (Coverage for Medical and Office visits)Medicaid

Medicare Part B ID# (red, white, and blue card for patients over 65)*

Rx BIN#*

This information is found on your PRESCRIPTION insurance card.

Rx PCN*

This information is found on your PRESCRIPTION insurance card.

Rx GROUP ID*

This information is found on your PRESCRIPTION insurance card.

Member ID#*

This information is found on your PRESCRIPTION insurance card.

Upload a photo of the patient's MEDICAL Insurance Card:

MEDICAID #: *

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Relation of Emergency Contact*

Lake Hills Pharmacy - Vaccine Scheduler

Appointment Scheduling

Patient Demographic Information

Patient Medical History

Patient Prescription & Medical Insurance

Emergency Contact Information