Book Your Vaccine Appointment — Park Ridge Pharmacy

Book Your Vaccine Appointment — Park Ridge Pharmacy

Complete this form to schedule your appointment and complete your health screening in one step.
Your Appointment
Preferred appointment date

MonthDayYear
Date
Preferred time
Vaccines requested
Patient Information
First Name
Last Name
Date of Birth

MonthDayYear
Date
Gender
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City / State / ZIP

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Care Provider Name
PCP Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Park Ridge Pharmacy Patient?
Insurance Information
Don't have your insurance info handy? No problem — bring your card and we'll look it up.
Prescription Benefit Plan Name
Cardholder ID #
Rx Group ID
BIN
PCN
Is the patient age 65 or older / Medicare eligible?
Medicare Part A/B ID Number (MBI)
Medical Insurance Provider
Medical Insurance Cardholder ID #
Is the patient the primary cardholder?
Caregiver / Authorized Representative
Caregiver Name
Relationship to Patient
Caregiver Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Immunization Screening Questions
Are you sick today?
Are you pregnant or planning to become pregnant within the next 3 months?
Do you have an allergy to gelatin, latex, yeast, neomycin, eggs, or any vaccine ingredient?
Did you have a serious reaction after a vaccine?
Do you have a history of dizziness or fainting before, during, or after vaccination?
Do you have a seizure, brain condition, nervous system condition, or Guillain-Barré syndrome (GBS)?
Do you have a weakened immune system due to cancer, HIV/AIDS, organ transplant, or another medical condition?
Have you taken immune-affecting medications or received radiation treatment in the past 6 months?
Have you received a COVID-19 vaccine in the last 2 months?
Have you had myocarditis, pericarditis, MIS-A, or MIS-C?
In the past year, have you received immune globulin, a blood transfusion, or another blood product?
Do you have a parent or sibling with an immune system problem?
Have you received any other vaccinations in the past four weeks?
Do you have any condition or risk factor as defined by the CDC?
Are you between 32 and 36 weeks pregnant at this visit?
Are you immunodeficient or immunosuppressed due to disease or therapy?
Do you currently have a cut, injury, or open wound that prompted getting a tetanus shot?
Consent & Authorization
Consent for Services
Authorization to Request Payment
Acceptance of Financial Responsibility
HIPAA Acknowledgment
Signature
Signature of Patient or Parent/Guardian
Date of Signature

MonthDayYear
Date
Name of Representative
Relationship to Patient
Should be Empty:

Book Your Vaccine Appointment — Park Ridge Pharmacy

Your Appointment

Patient Information

Insurance Information

Caregiver / Authorized Representative

Immunization Screening Questions

Consent & Authorization

Signature