Vaccine Request
Please enter as much information as possible. If you have any questions, please contact Eubank Drug at 254-694-3314.
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
/
Month
/
Day
Year
Date
Social Security Number
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Allergies
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Please submit your insurance information below. You may submit images of the front AND back of your cards OR enter the information from your card in the blanks below.
Front of Insurance Card
Browse Files
Cancel
of
Back of Insurance Card
Browse Files
Cancel
of
RX Bin (6 digits)
RX PCN (May be letters or numbers)
RX Group (May be letters or numbers)
ID Number (Please include letters if there are any)
I give Eubank Drug permission to process a claim to my insurance for the requested vaccine.
*
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Which of the following vaccines are you requesting? May select more than 1.
Flu
Tetanus
Meningitis
TDAP (Boostrix)
Pneumonia
Shingles
COVID-19
If requesting the COVID-19 vaccine, do you want the Moderna or Pfizer?
Moderna
Pfizer
If this is a booster, what was the date or estimated length of time since the most recent vaccine/booster?
If requesting the Pneumonia vaccine, have you received the Prevnar 13 vaccine?
Yes
No
Not Sure
If yes, what was the date or the estimated length of time since the vaccine?
If requesting the Tetanus shot, have you received the Tetanus shot in the last 10 years?
Yes
No
N/A
If yes, what was the date or the estimated length of time since the vaccine?
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Parental Consent
If you do not need vaccines for your child(ren), please skip this form.
Child's Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Child's Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Child's Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Parent or Guardian
First Name
Middle Name
Last Name
Relationship
I certify that I am the parent/legal guardian of the child(ren) listed above. I give consent for my child(ren) to receive the requested vaccine. I understand that the Vaccine Information Statement (VIS) will be provided at the time of service and that I am NOT obligated to have the vaccine administered after completing this form. (You may use the mouse on your computer to sign your name, if completing on your phone, please sign with your fingertip.)
Where do you plan to receive your vaccination from?
*
Eubank Drug
White Bluff VFD
Aquilla ISD
Blum ISD
Covington ISD
Whitney ISD
Itasca ISD
Grandview ISD
Other
If you selected "Other", list the location here.
Submit
Should be Empty: