09-06-2025 Windward Community College Flu Shot Drive Thru 2025-2026 - Flu Consent and Pre-Screening Form Logo

  • Influenza Vaccine

    Consent, Release, and Pre-Screening Form

  • Please complete all fields marked with a red asterisk (*)

    • Find your appointment month in the calendar below to view available dates and times.

  • Section 1 of 3 - Recipient Information

    All 3 sections are required for each vaccine recipient. All information is protected under HIPAA privacy laws. This form may only be completed and signed by one of the following: Vaccine Recipient, Parent, Legal Guardian, POA, or Authorized Signer.
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  • Primary Care Physician Information (PCP or MD)

    • If applicable, please provide your Primary Care Physician's information.

  • Section 2 of 3 - Insurance Information

    After your vaccination, Times Pharmacy will file an insurance claim using the information you provide us. Please check with your insurance provider if you are unsure of your coverage.

  • Please complete all fields marked with a red asterisk (*)

    • Medicare Information 

    • Medicare Insurance

      Please provide your Drug Insurance, Primary Insurance, and Secondary Insurance information if available.

      • Please provide any additional insurance information in the sections below.
      • Skip below to the "Next" button if Medicare coverage only.
    • Military Benefits Information 

    • Military Insurance

      • Please provide any additional insurance information in the sections below.
      • Skip below to the "Next" button if Military coverage only.
    • Primary Insurance Plan Information 

    • Primary Insurance Coverage

    • Other Insurance - Primary (If Applicable)

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    • We accept Kaiser and Kaiser Senior Advantage Insurance plans.

      We do not accept Kaiser Quest, Kaiser Medicaid, or Non-Hawaii Kaiser. 

      (Anyone who receives their vaccination with Kaiser Quest, Kaiser Medicaid, or Non-Hawaii Kaiser plans will be invoiced the out of pocket price of $62.50 - regular dose flu vaccine or $116.00 - senior dose flu vaccine.

       

       

    • Secondary Insurance Plan Information 

    • Other Insurance - Secondary (If Applicable)

       

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  • Section 3 of 3 - Pre-Vaccination Questions

    Please answer the screening questions below so that we may take appropriate precautions when needed.

  • Please complete all fields marked with a red asterisk (*)

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  • Consent & Release:

    I hereby certify that the information provided is correct, true, and complete to the best of my knowledge.

    I consent to receiving the above vaccine from Times Pharmacy.

    I understand that I am giving Times permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO, or insurance company, as applicable, to enable Times to process my insurance claims with respect to the vaccination. I, for myself, my heirs, executors, and assigns hereby release Times, and its divisions, and affiliates, and their respective officers, directors, employees, agents, and representatives from any and all claims arising out of or in connection with this vaccination. I also acknowledge that I received a copy of the Vaccine Information Statement (VIS) for the vaccine stated below and that I understand the benefits and risks associated with the described vaccine.

    This may be signed by the vaccine recipient, parent, legal guardian, POA, or authorized signer.  Please see a pharmacy staff memeber if you have any questions.

  • I understand that if my insurance does not pay for the services rendered on this form, I am responsible for payment.  I, for myself, my heirs, executors, and assigns hereby release Times, and it's divisions, and affiliates, and their respective officers, directors, employees, agents, and representatives from any and all claims arising our of or in connection with this vaccination.

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