Springfield Pharmacy Vaccination Consent Form Logo
  •  / /
  • For patients ages 3-17, please use our children's vaccine consent form: https://form.jotform.com/250864432371153

    Please note, we do not vaccinate children under the age of 3.

  • Current regulations require anyone under the age of 65 to have an underlying condition to receive the COVID vaccine without a prescription.  If you are under 65, please look at this list, if any one of them pretain to you, you qualify to receive the vaccine.  We will have you sign a form when you get to the pharmacy.  Thank you.

    CDC UNDERLYING CONDITIONS:
    ☐ Asthma
    ☐ Cancer
    ☐ Cerebrovascular disease
    ☐ Chronic kidney disease (People receiving dialysis)
    ☐ Chronic lung diseases (Bronchiectasis, COPD, Interstitial lung disease, Pulmonary embolism,
    Pulmonary hypertension)
    ☐ Chronic liver diseases (Cirrhosis, Non-alcoholic fatty liver disease, Alcoholic liver disease,
    Autoimmune hepatitis)
    ☐ Cystic fibrosis
    ☐ Diabetes
    ☐ Disabilities (Down syndrome)
    ☐ Heart conditions (heart failure, coronary artery disease, or cardiomyopathies)
    ☐ HIV
    ☐ Mental health conditions (Mood disorders, including depression, Schizophrenia disorders)
    ☐ Neurologic conditions (dementia, Parkinson's Disease)
    ☐ Obesity
    ☐ Physical inactivity
    ☐ Pregnancy and recent pregnancy
    ☐ Primary immunodeficiencies
    ☐ Smoking, current and former
    ☐ Solid organ or blood stem cell transplantation
    ☐ Tuberculosis
    ☐ Use of corticosteroids or other immunosuppressive medicines

  • Sorry, Due to high demand we do not currently have the following vaccine in stock.  All other vaccines are available, please click the back button to continue scheduling those vaccines. 

    - COVID-19


    Thank You!

  • Questionnaire

  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Privacy Policy

    Click here to review Springfield Pharmacy's Privacy Policy

    Vaccine Information Statements

    COVID-19 VIS   |  Influenza VIS  |  DTaP VIS  |  Hepatits A VIS |  Hepatits V VIS |  HPV VIS |  MMR VIS |  Polio VIS |  TDaP  VIS |  Chickenpox VIS  |  MCV4 VIS

    Other Vaccine Information Statements can be found by clicking here

  • Clear
  •  / /
  • By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

  •  
  • Should be Empty: