Lake Hills Pharmacy - Store Vaccine Scheduler

Appointment Scheduling

Please select a date and time for your vaccination appointment. If you selected multiple vaccines, they will be administered at the same appointment time.
Appointment: Please pick a day and time below (to see next month's appointments, click on the down arrow next to the current month)*

Patient Demographic Information
Patient Name*

PrefixFirst NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Gender: (M: Male and F: Female)*

MF
Patient Ethnicity*
Patient Race:*
Patient Email*
example@example.com
Patient Cell Phone Number: (Please double check for accuracy)*
Please enter a valid phone number.
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By providing this online form, I acknowledge that I understand the benefits and risks of the requested vaccination as described in the Vaccine Information Sheet, a copy of which is provided with this Consent and Release. I confirm that Lake Hills Pharmacy has answered to my satisfaction all of my questions about the vaccine and the vaccination procedure. I request and consent that the vaccination be given, as I direct Lake Hills Pharmacy, either to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release. I understand that I am giving Lake Hills Pharmacy permission to release any medical or other information necessary to my physician, Medicare, Medicare HMO or insurance company or immunization registry, as applicable, to enable Lake Hills Pharmacy to process my insurance claims with respect to the vaccination.

I, for myself (and for the recipient of the vaccination, if the recipient is a minor), my heirs, executors and assigns hereby release Lake Hills Pharmacy and its affiliates, owners, employees, agents and representatives from any and all claims arising out of or in connection with the quality of the above-described vaccine(s) as provided by the manufacturer and any negligence of the Lake Hills Pharmacy in connection with the related injection of the vaccination. I understand that the laws of my state may affect my remedies in connection with this vaccination.
Is the patient LESS than 18 years old, and/or UNABLE to provide medical consent for themselves?*

YesNo
Because the patient is less than 18 years old, who is providing authorized consent for this vaccine?Full Name of Authorized Entity*
Please enter relationship to patient that allows for authorization of medical consent(parent, legal guardian, power of attorney)Relation for authorization of medical consent*
Signature

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Patient Medical History

Enter Patient Medical History:*

	Yes	No	Don't know
Have you ever experienced a serious reaction after getting a vaccine?
Do you have allergies to medication, food, a vaccine component, or latex?
Do you have cancer, leukemia, HIV/AIDS, or other immune system problems, OR have you taken medications in the past 3 months that affect your immune system?
During the past year have you received a transfusion of blood, blood products, immune (gamma) globulin, or an antiviral drug?
For women: Are you currently pregnant or breastfeeding?
Have you received any vaccinations in the past 4 weeks?

If you answered "yes" to any of the questions above, please explain here:
Patient Prescription Insurance
Does the patient have health insurance?*

YES, I DO have health insuranceNO, I do NOT have health insurance (uninsured)
If you answered YES to the question above, please select which type of insurance you have: (Select All That Apply)*

Prescription Insurance (Coverage for medications at a pharmacy)Medicare Part A/B (Red, White, & Blue Card for patients over the age 65)Medicaid
Medicare Part B ID# (red, white, and blue card for patients over 65)*
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.
Upload a photo of the patient's PRESCRIPTION Insurance Card:

Cancelof
MEDICAID #: *
Should be Empty:

Lake Hills Pharmacy - Store Vaccine Scheduler

Appointment Scheduling

Patient Demographic Information

Patient Medical History

Patient Prescription Insurance