Lancaster 10/20

Town of Lancaster vaccine clinic
Location:Thayer Memorial Library

Address: 717 Main St

Date: 10/20/2026

Time: 3pm-6pm
If uninsured or registering a child under 5 years old please inform the staff at the time of clinic and you can skip filling out this form
Age
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number

Area CodePhone Number
Email Address
example@example.com
Vaccine(s) to receive?
Primary Care Provider (PCP) Name

First NameLast Name
Take a Picture of Your ID

Take Photo

Cancelof
Take a Picture of Your Insurance Cards

Take Photo
Upload front and back images of the insurance card. Cancelof
Insurance Information: Group Number
Enter the group number from your insurance card.
Insurance Information: Member ID
Enter your insurance member ID.
Insurance Information: PCN
Enter the PCN from your insurance card.
Insurance Information: Insurance BIN
Enter the BIN from your insurance card.
Medicare Card for 65+ years old

Take Photo

Cancelof
Medicare ID
Do you feel sick today?
Do you have allergies to latex, medications, food or vaccines (e.g., eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)?
If yes, please list:
Do you have any health conditions such as heart disease, diabetes or asthma?

Other
Do you have a condition that may weaken your immune system (e.g., cancer, leukemia, lymphoma, HIV/AIDS or transplant)?
Please list
When is the last time you received a vaccine?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you ever had a reaction after receiving an immunization, including fainting or feeling dizzy?
For women: Are you pregnant or considering becoming pregnant in the next month?
Form completed by?

First NameLast Name
Consent to Vaccination westminster pharmacy

I hereby claim that the above information is true and correct to the best of my knowledge. I consent that pharmacists affiliated with WESTMINSTER Pharmacy may administer this vaccine. I have been informed of the risks and benefits of the vaccine via the CDC-issued Vaccine Information Statement (VIS). I give permission to WESTMINSTER Pharmacy to seek compensation through my insurance, if applicable, knowing that my insurance may not fully cover the associated costs of the vaccine and administration. If this occurs, I understand that I am fully responsible for all costs associated with the administration of the vaccine. I also give consent to have this vaccine information shared as necessary with appropriate parties, including my healthcare provider and the immunization registry, MA Statewide Immunization Information System.
Signature
https://www.cdc.gov/vaccines/hcp/current-vis/downloads/flu.pdf
https://www.cdc.gov/vaccines/hcp/current-vis/downloads/rsv.pdf
https://www.immunize.org/wp-content/uploads/vis/covid-19.pdf
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Town of Lancaster vaccine clinic

Consent to Vaccination westminster pharmacy