All Vaccine Form

The Medicine Shoppe Vaccine appointment

All The Vaccine Provided by The Medicine Shoppe of Shillington
We make it easy for you to keep up with routine immunizations because we want you, your family, and everyone in the community to be at their best. Even though an appointment is not "required", it’s preferred for more efficient service. Most vaccines are covered by majority insurance with as little as $0 Co-Pay.

This universal form will be utilized for age groups 5 and above so if you are coming together as a family you will need to fill out 1 form per person.

Clinic Location: 101 W Lancater Ave Shillington, PA 19607

What do I need to bring with me:

- Any and all insurance information
Select the primary vaccine you wish to receive.
Select any secondary vaccine you wish to receive with the same appointment. You may get up to 4 vaccine at same time.
Select an appointment time: Please pick a day and time below (to see next month's appointments, click on the down arrow next to the current month) *If you selected multiple vaccines, they will be administered at the same appointment time --- if you are coming with a spouse or family member(s) select the closest appointment together & we will take you in together**
Email
example@example.com
Are you a customer or received any vaccine from The Medicine Shoppe in the past? (This will prevent us from creating duplicate profile)
First Name
Last Name
Vaccine Recipient Physical Address

Street Address

Street Address Line 2

CityState Initials

Postal / Zip Code
Date of Birth (5 y/o & up)

MonthDayYear
Gender
Vaccine Recipient Phone Number
Format: (000) 000-0000.
Which arm would you like the vaccine in?

Please answer "Yes" or "No" to the questions below concerning the patient's Medical History. The caregiver may fill this out on behalf of the patient. If unsure or you answer "Yes" to any of these and have concerns, please consult your doctor prior to receiving a vaccine. To save you time in person, we ask these questions now.

Rows	Yes	No
1. Are you feeling sick today?
Are you allergic to any vaccines, medications, or foods?
3. Have you ever had a serious reaction after receiving a vaccination?
4. Do you have any immune system condition or take medications affecting immunity?

For Women Only: Are you pregnant?
CONSENT & WAIVER: By clicking the box below, I am indicating my consent and agree my electronic signature is the legal equivalent of my manual signature on this Agreement. If I am signing on behalf of another individual (including a minor), I attest that I have the authority to do so. Please note that patients under 18 must have the consent of a parent or guardian. If I am receiving a COVID-19 vaccine dose, I attest I am eligible for that dose according to current recommendations from the CDC
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Date Signed

MonthDayYear
Date
Should be Empty:

The Medicine Shoppe Vaccine appointment