In-Home Vaccination Appointment Request

1
Patient Name* This field is required.
First Name
Last Name
2
Patient Address and address of Vaccination* This field is required.Please note this service is only for residents in Westchester County only
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
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District of Columbia
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Is this a private residence, apartment, or facility?* This field is required.
Private residence
Apartment
Facility
Other
4
Apt or Room Number
5
If applicable, please provide any parking or access instructions for our staff
6
Patient Phone Number* This field is required.
Please enter a valid phone number.
7
Patient Date of Birth* This field is required.
Date
Month
Day
Year
8
Gender* This field is required.
Male
Female
Other
9
Email Address* This field is required.
example@example.com
Confirm Email
10
Appointment* This field is required.
11
Which Vaccine would you like to receive* This field is required.
Flu Vaccine
Covid Vaccine
RSV Vaccine
Pneumonia Vaccine
Other
12
Do you have Insurance?* This field is required.
YESNO
13
Please provide us a picture of the front and back of your insurance* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
Most insurance plans, including Medicare, cover the cost of the in-home (at-home) vaccine administration fee. However, some insurance plans may not provide coverage for this service. Sunshine Pharmacy will verify your benefits before confirming your appointment. * This field is required.Please review and confirm each statement below:
I understand that my insurance may not cover the in-home administration fee.
If not covered, I agree to pay $50 per visit for the at-home vaccine service.
I authorize Sunshine Pharmacy to inform me before administration if the fee is not covered, and to request payment
15
At-Home Vaccine Service – Safety & Consent Acknowledgment* This field is required. By requesting an in-home vaccination visit, I acknowledge and agree to the following:
I confirm that the location where the vaccine will be administered is safe, clean, and free from hazards (e.g., aggressive pets, unsafe conditions, or other risks).
I will ensure that an adult (18 years or older) is present at the time of the appointment to receive or supervise the vaccine administration.
I understand that Sunshine Pharmacy staff will follow all required infection control and safety protocols during the visit.
I understand that Sunshine Pharmacy reserves the right to reschedule or refuse service if conditions at the location are deemed unsafe or unsanitary for the vaccinator.
I consent to the vaccinator entering my home for the purpose of providing the vaccination service and related documentation.
I release Sunshine Pharmacy and its representatives from liability for any injury, loss, or damage that may occur due to unsafe conditions at my property or circumstances beyond their control.
16
We are Sorry

You must agree to all statements to proceed. Please refresh this page to submit this form again or contact Sunshine Pharmacy at 914-607-3939 if you have questions.
17
Information of person completing this form* This field is required.
Full Name
Please enter your phone #
18
Signature of Authorized Representative* This field is required.
Clear
19
We’d love your feedback—was our scheduling tool simple and convenient for you?* This field is required.
YESNO
20
At Sunshine Pharmacy, we offer free delivery, personalized medication packaging, vaccine services, and one-on-one support. Would you be interested in making us your regular pharmacy?* This field is required.
Yes
No
Yes, but my insurance says I cannot use Sunshine
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