Vaccine and Appointment Request Form

Vaccine and Appointment Request Form

Let us know how we can help you!
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Sex/Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What date and time work best for you?
What is the best way to contact you?
How do you plan on paying for the vaccine and administration? (Select all that apply)
What reactions or problems have you experienced with any vaccines or drugs? You can also type any questions you have about the requested vaccine or anything else you would like to discuss before or during your appointment.
Vaccines Requested

Other
By signing below, I am acknowledging that:

1. I have read the important information published by the CDC about the vaccine(s).

2. In the event of a severe allergic reaction, I am giving consent for the pharmacist to administer epinephrine, CPR, provide other necessary measures and call 9-1-1.

3. If I have checked “Medicare Part-B”, I choose to assign benefits to Howard’s Drug to bill Medicare on my behalf.
Have you ever had a severe reaction to a vaccine, or to a drug?
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: