Wellness Pharmacy COVID-19 Vaccine Appointment Form 2024-2025 SEASON

Wellness Pharmacy COVID-19 Vaccine Appointment Form 2024-2025 SEASON

WE HAVE PFIZER AND MODERNA
Requirements for Vaccination of COVID-19 VACCINE

INSURANCE IS NOT REQUIRED, HOWEVER IN THE EVENT THAT YOU CHOOSE TO PAY OUT OF POCKET, THE PRICE FOR THE COVID-19 VACCINE IS $206.77. EVEN WITH INSURANCE, YOU MAY HAVE COPAY. AT THE TIME OF YOUR APPOINTMENT, YOU WILL BE INFORMED OF THE COPAY AND YOU WILL HAVE THE RIGHT TO SAY 'NO' IF THE COPAY IS TOO HIGH. FOR MOST PEOPLE, THE COPAY THROUGH INSURANCE IS $0.
Criteria for our Covid-19 Vaccine:

Must be 12 years of age and older and have had the Covid-19 shot at least 2 months ago.

*** An email address will be used to confirm your appointment. In the unlikely event that you are not on our appoinment list, we will ask you for your confirmation email as proof of registration. Those without proof may be asked to schedule an appointment for a later date.
Appointment - IF ALL DATES ARE GRAYED OUT, THAT MEANS NOTHING IS AVAILABLE AT THIS TIME*
Which vaccine are you booking on your selected date?*

Moderna SpikevaxPfizer Comirnaty
Did you want your flu shot as well?*

Yes, give it to me during the appointment (if you are older than 65 years of age, we are assuming you want the high dose flu shot unless you state otherwise at the time of your appointment)No, I will get it done another day at my favorite pharmacy in the Upper West Side
Salutation
First Name*
Middle Initial
Last Name*
Suffix
Date of Birth. Must be Older than 12 years of age.*

MonthDayYear
Date
CellPhone
Primary Phone*
Please enter a valid phone number.
Primary Phone Type*

CellHome
Email *
example@example.com
Address*
AddressTwo
City*
State Code (NY for New York)*
ZIP*
CountyOfResidence
Questionnaire
Race*
What is your ethnicity?*
Gender?*
Language
Mother's Maiden Name (only required for those 18 AND YOUNGER)
Guardian
DriverLicenseState
DriverLicenseNumber
DrugAllergies
HealthConditions
PcpName
PcpPhone
PcpAddressOne
PcpAddressTwo
PcpCity
PcpStateCode
PcpZip
Employer
HealthcareWorker
SocialSecurityNumber
MedicareBeneficiaryIdentifier
InsuranceType
Insurance Info

For the next section, WE REQUIRE YOUR PART B card if you have Medicare.
RX BIN (on insurance card)
RX PCN (on insurance card)
RX Group (on insurance card)
ID Number (on insurance card 1) Write ‘Uninsured’ if no insurance. THE COST OUT OF POCKET FOR COVID-19 SHOT IS $206.77 TO BE PAID AT THE TIME OF VACCINATION*
Relationship on the card (if Uninsured, check 01 Self)*

01 Self02 Spouse03 Child04 Other
InsuranceEffectiveDate
InsuranceType2
RxBin2
RxPcn2
RxGroupID2
MemberID2
Relation2
InsuranceEffectiveDate2
PrescriberFirstName
PrescriberLastName
PrescriberNpi
WrittenDate
Quantity
UnitOfMeasure
Refills
Directions
DispensedItemNDC
DispensedQuantity
DaysSupply
Lot
LotExpiration
PharmacistFirstName
PharmacistLastName
PharmacistNpi
DoseNumber
AdministrativeSite
AdministeredDate
AdministrationLocation
TpoCode
FundingSource
VaccineForChildEligibility
RouteOfAdministration
ReportToRegistry
By signing below, I'm attesting that the information submitted is true to my knowledge.
Signature*

Clear
Should be Empty:

Wellness Pharmacy COVID-19 Vaccine Appointment Form 2024-2025 SEASON

Requirements for Vaccination of COVID-19 VACCINE

Questionnaire

Insurance Info