CGCC Vaccine Clinic Registration

Kelly's Pharmacy Vaccine Registration

Please fill out this form carefully with your information. Your details are protected under HIPAA. Kelly’s Pharmacy Inc. will use this information to create your profile and check your prescription insurance so we can bill your vaccine correctly. *Please bring your insurance card with you to the clinic—just in case we need it.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Last 4 of SSN *
Needed to search for prescription insurance eligibility.
Allergies
Insurance Information

If available, please complete the information below. If completing this form on a mobile device, you may take a photo of the front & back of your prescription insurance card, rather than typing the information in.
Name of Insurance
ID Number
Rx BIN# (6 Digits)
Rx PCN
Rx Group
Front of Card
Back of Card
Vaccine Clinic Date*

MonthDayYear
Date
Vaccine Appointment*
Additional Comments
Vaccine(s) You Are Requesting*

Flu (Afluria/Fluad65+ -age dependent)COVID-19 (Moderna)Shingles (Shingrix)Pneumonia (Prevnar 20)
If you'd like, you may download, print & fill in the vaccine consent form below to bring with you to your vaccine clinic. *This must be dated the date you're receiving the vaccine.
Should be Empty:

Kelly's Pharmacy Vaccine Registration