University of Akron - Wayne Campus Vaccine Clinics (2024-25)

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University of Akron Wayne Campus Vaccine Clinic

Monday, October 14 - 11am-2pm
Location: Room F102
Which vaccine(s) would you like to receive? NOTE: while we hope to have COVID-19 vaccine, there have been intermittent backorders that may affect availability at the clinic*

Influenza (flu)COVID-19 (2024-25)
PATIENT Name*

First NameLast Name
PATIENT Date of Birth (MM/DD/YYYY)*
PARENT/GUARDIAN Name (<18yo)

First NameLast Name
Email*
example@example.com
Address*
City*
State*
Zip Code*
Phone*
Gender*

MaleFemaleWish not to disclose
Weight (if < 66lbs)
Primary Care Provider (PCP) - Optional:
Billing

Please bring your Medical/Rx insurance card to your vaccine appointment. If you do not have Medical/Rx insurance you will need to provide your Social Security number.
Would you like us to bill insurance for a free vaccine or pay at the time of service? (flu $40, COVID $150)*

InsuranceCash/Check
Cardholder Name:*
Cardholder Date of Birth (MM/DD/YYYY)*
Relationship to Cardholder (ie. cardholder, spouse, child)*
Insurance Card Image

Cancelof
MEDICAL Insurance Provider Name (eg: Aetna, Cigna, SummaCare, etc.) *
MEDICAL Insurance ID #*
MEDICAL Insurance Group Number*
Rx Insurance ID*
Rx BIN Number*
Rx Group (GRP) Number*
Rx PCN Number*
Are you feeling sick today?*

YesNo
Do you have allergies to antibiotics (neomycin, polymyxin-B), eggs, a vaccine component, or latex?*

YesNo
Have you ever had a serious reaction after receiving a vaccination or an injectable medication?*

YesNo
Have you had a seizure, brain, or other nervous system problem (ex. Guillain-Barre Syndrome) within 6 weeks of receiving a previous flu vaccine?*

YesNo
Have you received your annual 2024-2025 COVID-19 vaccine?*

YesNo
When did you receive your last COVID-19 vaccine (date)?
Influenza Vaccine Information Statement
COVID-19 Vaccine Information Statement
Please review the Vaccine Information Statements prior to receiving your vaccine. Thank you!
Vaccines are adminstered in accordance with the recommendations provided by the Advisory Committee on Immunization Practices (ACIP) and the CDC.

Medicare/Medigap Policy Holders: I request that the payment of authorized Medicare benefits and, if applicable, Medigap benefits, be made on my behalf to NEOvations Pharmacy Services, LLC for any services furnished to me by NEOvations Pharmacy Services, LLC. I authorize the release of any holder of medical information about me to release to the Centers for Medicare and Medicaid Services, my Medigap insurer, and their agents, any information necessary to determine these benefits or benefits payable for related services.
Joint Notice of Privacy Practices ("Notice")*

The Joint Notice of Privacy Practices (“Notice”) describes your rights in regard to your protected health information, the possible uses of your protected health information, and how we must protect the confidentiality of your protected health information. By checking here, you are stating you have received a copy of the "Notice" which is provided to you electronically below.
Joint Notice of Privacy Practices ("Notice")
Signature (Parent or Legal Guardian if < 18 years)*

Clear
Print Full Name*
Flu Lot
PHARMACY USE ONLY
Flu Expiration
PHARMACY USE ONLY
COVID-19 Lot
PHARMACY USE ONLY
COVID-19 Expiration
PHARMACY USE ONLY
Flu Shot Site (PHARMACY USE ONLY)

Left DeltoidRight Deltoid
COVID-19 Shot Site (PHARMACY USE ONLY)

Left DeltoidRight Deltoid
Supervising RPh
PHARMACY USE ONLY
Provider:
PHARMACY USE ONLY
Should be Empty:

University of Akron Wayne Campus Vaccine Clinic

Location: Room F102

Billing