Swarthmore College Faculty and Staff Vaccination Consent Form

Welcome to Fall 2025 vaccine clinic for Swarthmore College Faculty and Staff provided by Springfield Pharmacy. We will have 2 separate clinics to best accommodate your schedule.

If you have any questions please email vax@myspringfieldpharmacy.com

Thank you
Please select which date you would like to schedule your vaccine. *

Please select an arrival time for Tuesday, September 23.*

Please select an arrival time for Wednesday, October 8.*

Full Name First MI Last*
Date of Birth*

MonthDayYear
Date
Age*
Email*
example@example.com
Phone*
Address*

Address

Street Address Line 2

CityState

Zip Code
Primary Care Doctor Name
Primary Care Doctor City/State
Vaccines to receive*

Flu ShotCOVID (2025 formulation)

INSURANCE INFORMATION*

I hereby authorize the pharmacy to bill my insurance on my behalf for vaccine administration fee & receive payment.I do not authorize the pharmacy to bill my insurance
By selecting "I do not authorize the pharmacy to bill my insurance," you are agreeing to pay cash for your vaccines at the time of administration. Cash price for Flu for people under the age of 64 is $50, Flu for people age 65 or older is $85 and COVID is $160. Please have cash with you at your appointment. Please sign below saying you agree and will have cash. *

Clear
Insurer*
Member*
Rx Group*
BIN*
PCN*
Medicare Part B Number
Last 4 digits of your SSN*
Upload a photo of your insurance card below*

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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
ACKNOWLEDGEMENTS*

I attest that the answers provided here are accurate to the best of my knowledge.I understand the benefits and risks of the vaccination(s) as described in the Vaccine Information Sheet (VIS) or Emergency Use Authorization (EUA), a copy of which I was provided with this Consent & Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent & Release.I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy & of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature*

Clear
Date*

MonthDayYear
Date
Name of person signing*
Relationship to patient*
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.
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Questionnaire