Overture Arboretum

Overture Arboretum & Tarrytown Pharmacy Vaccine Clinic Registration and Consent

Tarrytown Pharmacy will be taking care of your vaccines this year with an on-site clinic! Please fill out this HIPAA-secure form prior to the clinic in order to receive the vaccine. Online sign-ups will be available until 24 hours prior to the clinic.
Patient Name

FirstNameLastName
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDateOfBirth
Appointment Scheduling

Please select a date and time for your vaccination appointment. If you will be receiving multiple vaccines, they will be administered at the same appointment time.
Appointment: Please pick a day and time below (to see next month's appointments, click on the down arrow next to the current month)

Vaccine Selection
Please select which vaccines you would like to schedule an appointment for (Select ALL that apply):
Patient Age Calculated (In Years):
Select which FLU SHOT best applies: Ages 3 to 64
Select which FLU SHOT best applies: Ages 65 and Older
Select which COVID-19 vaccine: Ages 3 to 4
Select which COVID-19 vaccine: Ages 5 to 11
Select which COVID-19 vaccine you prefer: Ages 12 and up
COVID-19 Attestation
Other Immunizations:

Other
Patient Demographic Information Continued
Patient Gender (as associated with your insurance):
Patient Email
example@example.com
Patient Cell Phone Number: (Please double check for accuracy)
Please enter a valid phone number. Only enter the numbers no ( ) or dashesFormat: 0000000000.
Patient Address

AddressOne

AddressTwo

CityStateCode

Zip
Date of Appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Prescription Insurance
Does the patient have health insurance?
By selecting this box, you are acknowledging that you do not have insurance coverage, and you will pay for the selected vaccines out of pocket, unless your company has opted to cover uninsured employees (check with your company if you aren't sure). Flu shots are discounted to $35 out of pocket at all clinics, and the prices of other vaccines vary. You can pay by credit/debit card at the clinic before receiving the vaccine and may opt out any time.
Please upload a picture of your insurance card(s):

Cancelof
Patient Medical History

Enter Patient Medical History:

Rows	Yes	No	Don't know
Have you ever experienced a serious reaction after getting a vaccine?
Do you have allergies to medication, food, a vaccine component, or latex?
Do you have cancer, leukemia, HIV/AIDS, or other immune system problems, OR have you taken medications in the past 3 months that affect your immune system?
During the past year have you received a transfusion of blood, blood products, immune (gamma) globulin, or an antiviral drug?
Have you had a seizure or another brain or nervous system disorder?
Are you currently pregnant or breastfeeding?
Have you received any vaccinations in the past 4 weeks?

If you answered "yes" to any of the questions above, please explain here:
Is the patient LESS than 18 years old, and/or UNABLE to provide medical consent for themselves?
Acknowledgement, Consent, and Authorization
By signing, I certify that I am the patient, the patient's parent or legal guardian, or otherwise legally authorized to consent on the patient's behalf, and I voluntarily consent to administration of the vaccine(s) selected above. I acknowledge that I have received or been given the opportunity to review the applicable Vaccine Information Statement (VIS), EUA Fact Sheet (when applicable), or other required educational materials. I have had the opportunity to ask questions and understand the benefits and potential risks of vaccination. I acknowledge receipt of Tarrytown Pharmacy's Notice of Privacy Practices. I authorize Tarrytown Pharmacy to submit claims to my insurance or other third-party payer, release information as permitted by law for payment and healthcare operations and receive payment for services provided. I understand that I may be responsible for charges not covered by my payer. I understand that immunization information may be reported to ImmTrac2 or other applicable immunization registries as permitted or required by law. I understand that separate consent may be required for participation in ImmTrac2. I certify that the health information and screening responses I provided are complete and accurate to the best of my knowledge and that I have disclosed any allergies, medical conditions, medications, or previous vaccine reactions that may affect vaccination.
By signing this form, I hereby accept that:
- I declare that the information I have provided above is accurate.
- I am giving my full consent to get the flu vaccine or other requested vaccinations of my own will.
- If I miss my appointment for any reason, or need to reschedule, I will have to book a new appointment if available.
- I will show up on time for my appointment.
- I am consenting that the company providing the vaccine clinic in conjuction with Tarrytown Pharmacy can know that I am receiving the selected vaccines. They will not have access to any other medical information provided on this consent form.
- I have been provided with the current CDC Vaccine Information Statements.
Date of Form Completion

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Because the patient is less than 18 years old, who is providing authorized consent for this vaccine?Full Name of Authorized Entity*. Please enter relationship to patient that allows for authorization of medical consent(parent, legal guardian, power of attorney) Relation for authorization of medical consent*
Signature of patient or authorized person for consent
Comments, Notes, or Questions for Tarrytown Pharmacy
Should be Empty:

Overture Arboretum & Tarrytown Pharmacy Vaccine Clinic Registration and Consent

Appointment Scheduling

Vaccine Selection

Patient Demographic Information Continued

Patient Prescription Insurance

Patient Medical History

Acknowledgement, Consent, and Authorization