10/15/26 Swarthmore Borough Vaccine Clinic Consent Form

Welcome to the online registration for Swarthmore Borough Vaccine Clinic on October 15, 4pm-6pm provided by Springfield Pharmacy.

If you have any questions please email vax@myspringfieldpharmacy.com

Thank you!
We can only vaccinate children ages 3 and up. If your child is less than 3 years of age, please contact their physician to schedule a vaccination appointment.
Please select the age range you are scheduling a vaccine for.

CHILD VACCINE FORM PATIENT INFORMATION
Patient Full Name (First MI Last)
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Age
Gender
We can only vaccinate children ages 3 and up. If your child is less than 3 years of age, please contact their physician to schedule a vaccination appointment.
Email
example@example.com
Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Doctor
Provider City, State
Emergency Contact Name
Emergency Contact Phone
Format: (000) 000-0000.

INSURANCE:
Insurance
By selecting "I do not authorize the pharmacy to bill my insurance," you are agreeing to pay cash for your vaccines at the time of administration. Cash price for Flu for people under the age of 64 is $50, Flu for people age 65 or older is $85 and COVID is $160. Please have cash with you at your appointment. Please sign below saying you agree and will have cash.
Insurance Company Name
Insurance ID Number
Rx Group
BIN
PCN
Upload a photo of your insurance card below

Cancelof

ACKNOWLEDGEMENTS
Privacy Policy

Click here to review Springfield Pharmacy's Privacy Policy

Vaccine Information Statements

COVID-19 VIS | Influenza VIS | DTaP VIS | Hepatits A VIS | Hepatits V VIS | HPV VIS | MMR VIS | Polio VIS | TDaP VIS | Chickenpox VIS | MCV4 VIS

Other Vaccine Information Statements can be found by clicking here
Acknowledgements

I have received a copy of the notice of Privacy Practices and appropriate CDC Vaccine Information Statement (VIS I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the Pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Parent/Guardian
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of person signing
Relationship to patient

ADULT VACCINE FORM PATIENT INFORMATION
Patient Full Name (First MI Last)
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Age
Gender
Email
example@example.com
Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Doctor
City, State of Primary Care Doctor

INSURANCE:
Insurance
By selecting "I do not authorize the pharmacy to bill my insurance," you are agreeing to pay cash for your vaccines at the time of administration. Cash price for Flu for people under the age of 64 is $50, Flu for people age 65 or older is $85 and COVID is $160. Please have cash with you at your appointment. Please sign below saying you agree and will have cash.
Insurance Company Name
Insurance ID Number
Rx Group #
BIN
PCN #
Medicare Part B
Last 4 digits of your SSN
Upload a photo of your insurance card below

Cancelof

ACKNOWLEDGEMENTS
Privacy Policy

Click here to review Springfield Pharmacy's Privacy Policy

Vaccine Information Statements

COVID-19 VIS | Influenza VIS | DTaP VIS | Hepatits A VIS | Hepatits V VIS | HPV VIS | MMR VIS | Polio VIS | TDaP VIS | Chickenpox VIS | MCV4 VIS

Other Vaccine Information Statements can be found by clicking here
Acknowledgements

I have received a copy of the notice of Privacy Practices and appropriate CDC Vaccine Information Statement (VIS I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the Pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
Signature of Patient/Parent/Guardian
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of person signing
Relationship to patient

Schedule your arrival time for Thursday, October 15
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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