Hawthorne: Vaccine Clinic (Fall 2026)

Vaccine Scheduling and Consent Form

Please read below carefully, fill out the form to the best of your knowledge. To space out appointment times and minimize wait times, we have created this HIPAA-secure electronic sign up form. There will be two clinic dates: Tuesday, October 6th and Tuesday, October 20th. The clinics will take place from 9 AM to 12 PM in the Lemon Lime Room of the Hawthorne Clubhouse. If you have any questions about the vaccines, please reach out to a staff member at Burry's Pharmacy, (352)787-3787.
The following vaccines will be available this year:
- COVID Boosters: Updated, monovalent booster doses (Fall 2026) for both Moderna and Pfizer COVID-19 vaccines
  - Annual vaccine
  - Comirnaty (Pfizer) and Spikevax (Moderna) will be available
  - Eligible patients:
    
    65 years and older (at least 2 months after previous booster)
    
    5 years through 64 years of age at a high risk for severe COVID-19*
    
    *May include asthma, cancer, cerebrovascular disease, CKD, chronic lung disease (COPD, Pulmonary embolism, pulmonary HTN), chronic liver diseases, cystic fibrosis, Diabetes, heart conditions, HIV, mental health conditions, neurologic conditions (dementia, Parkinson’s disease), obesity, physical inactivity, pregnancy, primary immunodeficiencies, smoking, solid organ or blood stem cell transplantation, tuberculosis, use of corticosteroids or other immunosuppressive medications
- Flu Shots: Age appropriate flu doses
  - Annual vaccine
  - Fluzone (regular dose) and Fluad (65 years and older) will be available
- RSV Shots:
  - Single, one-time dose (not an annual vaccine)
  - mResvia will be available
  - Eligible patients:
    
    Ages 60 years and older
    
    Ages 18 years through 59 years who are at increased risk for lower respiratory tract disease caused by RSV*
    
    *See conditions listed above
- Pneumonia Shots:
  - Not an annual vaccine
  - Prevnar 20 (PCV20) will be available
  - Eligible patients:
    
    Adults 50 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown
    
    Based on shared clinical decision-making, adults 65 years or older have the option to get PCV20 or not get additional pneumococcal vaccines
    
    If they have received both PCV13 (but not PCV15, PCV20, or PCV21) at any age
    
    And PPSV23 at or after the age of 65 years old
Which vaccination(s) would the patient like to receive? (Select all that apply)
Select the patient's age category below:
Which COVID monovalent booster does the patient need?
Are you handicapped or disabled and will require an in-home visit?
Appointment Date and Location

Tuesday, October 6th and Tuesday, October 20th: Lemon Lime Room in Hawthorne Clubhouse
Please select an appointment time. Click on October 6th or October 20th to see available appointment times.
Patient Demographic Information
Name

FirstNameLastName
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com (We will send a confirmation and reminder email here)
Home Address

AddressOne

AddressTwo

CityStateCode

Zip
Race
Ethnicity
Patient Prescription Insurance
Do you have health insurance?
Rx BIN
This information is found on your PRESCRIPTION insurance card
Rx PCN
This information is found on your PRESCRIPTION insurance card
Rx GROUP ID
This information is found on your PRESCRIPTION insurance card
Member ID
This information is found on your PRESCRIPTION insurance card
Medicare Part B ID (If 65 years or older or have Part B coverage)
Red White & Blue Card
Emergency Contact Information
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Patient Medical History

Rows	Yes	No	Don't Know
Are you currently sick with a fever today?
Do you have allergies to a vaccine ingredient or latex?
Have you ever had a serious reaction after receiving a vaccination?
Have you ever been diagnosed with a heart condition (myocarditis or pericarditis) or have you had Multisystem Inflammatory Syndrome (MIS-A or MIS-C) after an infection with the virus that causes COVID-19?
Have you ever felt dizzy or faint before, during, or after a vaccine?
Have you received any vaccinations in the past 4 weeks?

Vaccine Acknowledgement
I request and authorize Burry’s Pharmacy and its authorized healthcare providers to administer the vaccine(s) indicated on this form. I authorize Burry’s Pharmacy to submit claims and receive payment for vaccination services from my insurance carrier, including Medicare Part B, Medicare Advantage, or other medical or pharmacy benefits. I authorize the release of necessary medical and billing information to my insurance plan, healthcare providers, and public health authorities as required for treatment, payment, and healthcare operations.

I understand that vaccination, like any medical treatment, carries some risk, and I release Burry’s Pharmacy and its healthcare providers from liability for
adverse outcomes except in cases of negligence or willful misconduct. I consent to the documentation of this vaccination in Florida’s state immunization
registry, as required by law.

Any patient receiving testing, screening, or treatment services is advised to seek follow up care from his or her primary care physician.

By signing this form I hereby accept that:
- I have read and understood the acknowledgment letter provided above.
- I declare that the information I have provided above is correct.
- I am giving my full consent to get the requested vaccine of my own will.
- I will show up ON TIME for my appointment
- I am eligible to receive the vaccine(s) for which I signed up for based on the description above
- I understand the benefits and potential risks of vaccination and have had the opportunity to ask questions.
- I have been provided with the Vaccine Recipient Fact Sheet
Date of Form Completion

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
If you have any additional questions, please list them here and a team member will follow up with you.
Should be Empty:

Vaccine Scheduling and Consent Form

Appointment Date and Location

Patient Demographic Information

Patient Prescription Insurance

Emergency Contact Information

Patient Medical History

Vaccine Acknowledgement