iPharma Pharmacy Flu Vaccine

Flu Vaccine Appointment Form

Fill the form below and we will get back soon to you for more updates and plan your appointment.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Required Documents and Arrival Instruction:
- Please bring your ID and insurance card with you to your appointment.
- Please bring your vaccination record card (if applicable)
- Please arrive at least 15 minutes prior to your appointment time.
- Please allow 30 minutes upon arrival. You will be required to remain on-site for 15 minutes for observation. Additional instructions will be provided upon arrival.
- If the patient is 17 years of age or less, a parent or legal guardian must accompany the patient during the vaccine process. If readily accessible, please bring the child's ID or birth certificate.
The flu vaccine is typically covered by insurance free of charge. Please upload your
insurance card below (front and back).
Please acknowledge*

I agree with the required documents and arrival instructions section
Please select one*

Insurance CardNo Insurance Card
Cash Pricing:
- $45 for Afluria
- $70 for Fluzone
Select your Vaccine*

AfluriaFluzone
Upload the FRONT of the insurance card*

Cancelof
Upload the BACK of the insurance card*

Cancelof
Preferred Appointment Date *
Please acknowledge*

Yes, send me text messages for this appointment.
Should be Empty:

Flu Vaccine Appointment Form