• A COVID and Flu Vaccination Event:

    {site}
    {location}

    10-23-2026
    9-2:00p

  • Please read this entirely and fill out the required details below. This form is HIPAA Compliant.

  • Clinic Information

    1. Village Apothecary is Your Vaccinator

    This clinic is in partnership with Village Apothecary of Woodstock, NY.

    If you have any questions about these vaccines or the vaccine event itself, please reach out to us at 845-679-0790 or via email at covid@villageapothecaryrx.com. Ask for the onsite vaccine team.

     

    2. Vaccine Update 2026

    New York has passed legislation protecting access to vaccines.

    Anyone who wants a COVID-19 or flu vaccine can receive one with no prescription needed.

    Read our 2026 Vaccine Update here to learn about vaccine options.  One of our healthcare professionals can recommend the best vaccine for you based on your unique needs.

    3. Insurance Coverage is Required

    All patients MUST bring their active PHARMACY BENEFITS information.

    Preregistering with this form USUALLY allows us to identify issues prior to the clinic date.

    You may be denied vaccination if the correct information is not present at the clinic date.  

    Patients can pay out of pocket for vaccines.  Contact us at 845-679-0790 to discuss.

     

    • More Info On What Insurance Info We Need + 

    • Here are examples of what information we will require based on your coverage type:

      • Commercial insurance - Rx Bin, Rx PCN, Rx ID, and Rx Group Number
      • NY Medicaid - We'll need your CIN number
      • Tricare - We'll need the enlisted servicemember's SSN

      Other Payment-Related Information

      • Some patients may not have coverage for the vaccine, despite having medical/pharmacy benefits
      • Patients that are uninsured but still want vaccination can pay for the vaccine. 

      If you have any concerns, please contact our Onsite Vaccine Team at 845-679-0790 to check coverage in advance of the clinic.

  • 1. Vaccine Selection

  • Which COVID vaccine would you like?*
  • Would you like a flu vaccine?*

  • For Bard uninsured faculty, staff, and students, Village Apothecary will be offering a free flu shot this year.  We will attempt to identify insurance coverage for every patient, so please still bring ID + any insurance cards you do have.

  • Which arm would you prefer the vaccine(s) be administered?*

  • 2. Patient Information

  • NAME: When entering your name, enter your LEGAL name and do NOT write middle initials. PLEASE write any suffix (Jr, III).

  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Address Information

    ATTENTION: If you are a college student, please enter the address that is associated with your insurance (usually a HOME address). Otherwise, use your COLLEGE address.

    If you are an international student, please use your COLLEGE address.

  • Please select the best description of your gender.

    Gender is required for insurance claim processing, so please ensure your selection here matches what is currently on file with any insurance provider.

    These values are set by the NYS DOH and insurance carriers, not Village Apothecary.

  • Gender*

  • Primary Care Doctor Information

    Please enter your primary care provider's (PCP) name and city/state.  If you do not have one, write N/A in both fields.

  • Do you have any allergies to medications, vaccines, or their components?

    If so, please list them.

  • Allergies*

  • 3. Screening and Attestations

  • Required Documents

    In an attempt to reduce paper waste, all legally required documents must be downloaded here by clicking the links.

    Very limited copies will be available on clinic day.

    If you are completing this on behalf of someone else, please download these documents and supply them to the patient.

    COVID-19 Vaccine Information Statement

    Flu Vaccine Information Statement

    Notice of Privacy Practices

     

  • Certification

    • By signing up for immunization with Village Apothecary, you are agreeing to provide your insurance or identifying information AND are willing to provide verification of any incomplete information at a later date IF a staff member reaches out to you.
    • I certify that I have received, read, and understand Vaccine Information Statement.
    • I certifty that I have received the Notice of Privacy Practices.
    • I understand the benefits and risks of the vaccination, as described in the Vaccine Information Statement, a copy of which I was provided with this registration.
    • 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.
    • I certify that vaccination records will be submitted to the NYS Immunization Information System (NYSIIS).

    Please type your full name in the box below. You agree your typed full name represents your electronic signature is the legal equivalent of your manual signature on this form.

  • Insurance Billing for the Administration of the Vaccine*

  • IF YOU ARE INSURED, PLEASE BRING YOUR INSURANCE CARD THAT HAS YOUR PHARMACY BENEFITS INCLUDED ON IT.

    This could be:

    • Medicare Part B
    • Caremark
    • Express Scripts
    • Optum
    • Or any card that has an RxBIN number on it!

    TRICARE BENEFICIARIES: We need the FULL SSN of the military member on clinic day.

     

    The active pharmacy benefits information must be present at the time of administration. You will not be vaccinated without up to date information.

     

  • 4. Appointment Selection

    Pick the day you wish to attend, then the time.

  • APPOINTMENT DATE & TIME*
  •  :

  • 5. Submission

  • Submit only one entry per person.

    If you need to reschedule, just arrive at the new time; no need to notify us of the change.

    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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