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
Sex/Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What date and time work best for you?
Text messagePhone callE-mail
Private insuranceMedicare Part-BMedicare AdvantageCash/out of pocketUninsuredOther (e.g., employer sponsored event)
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.
Flu shot - standardFlu shot - nasalFlu shot - for those aged 65+Tdap (Tetanus, diphtheria, pertussis)Shingles (Shingrix)Hepatitis B (Heplisav-B)MeningococcalPneumococcal (e.g., Prevnar-20)RSVTravel consultation + any recommended vaccines and medicinesAppointment for medication administrationOther
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.
YesNoUnsure
Signature
Date

MonthDayYear
Date
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