General Routine Vaccinations

This form is for our Danvers, MA location only.

Unsure of which vaccines to get? Click here to complete a short quiz to find out what vaccines you may be eligible for.

Select the vaccine recipient's age:*

12+65+

Date of Birth*

Date

For patients UNDER 12 years old

We currently do not offer online appointments for recipients under the age of 12. Please give us a call at (978) 705-0007 if you have any questions about the availability of other vaccines for this age range.

For patients between 12 and 50 years old, we offer the following:

COVID-19 Vaccine (Pfizer or Moderna)
Learn more about the available Moderna vaccines
Flu Shot (Influenza Vaccine)
TDAP
HPV (human papilloma virus)
Hepatitis (Twinrix A+B only)
RSV (only during weeks 32-36 of pregnancy)

Please give us a call at (508) 202-9993 if you have any questions about the availability of other vaccines for this age range. Thank you!

Patients between 50 and up, we offer the following:

COVID-19 Vaccine (Pfizer or Moderna)
Learn more about the available Moderna vaccines
Flu Shot (if 65+ will receive the recommended high dose flu shot)
TDAP
HPV (human papilloma virus)
Hepatitis (Twinrix A+B only)
Shingles
Pneumonia
RSV

Please give us a call at (508) 202-9993 if you have any questions about the availability of other vaccines for this age range. Thank you!

Which vaccine(s) would you like to receive? You can have multiple vaccinations in 1 visit.*

(12+) Which COVID-19 vaccine would you like to receive?

Moderna Spikevax (12y and over)Moderna mNEXSPIKE (12y and over)Pfizer (12y and over)

Appointment*

Name*

First NameLast Name

Calculated Age

Gender*

FMNon-binaryPrefer not to say

Cell Phone*

Home Address*

Address

Street Address Line 2

CityState / Province

Zip

Email Address*

example@example.com

Allergies*

Please answer the following:*

	Yes	No	Don't Know
Do you feel sick today?
Do you have allergies to medications, food, eggs, yeast, a vaccine component, or latex?
Have you ever had a reaction after receiving a vaccination, including feeling dizzy or fainting?
Do you have any health conditions such as heart disease, lung disease, liver disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorder?
Have you had a seizure, Guillain-Barre syndrome, or a brain/other nervous system problem?

For women: Are you pregnant or is there a chance you could become pregnant during the next month?

YesNoI don't know

For Tdap: Do you have a cut, injury, puncture wound, or open wound that prompted you to get a tetanus shot?

YesNoI don't know

Have you tested positive for COVID-19 in the last 3 months?

YesNoI don't know

If you answered yes to the question above, did you receive antibody therapy for COVID-19 monoclonal antibodies or convalescent plasma?

YesNoI don't know

Do you have a weakened immune system due to a health condition or immunosuppressive therapy?

YesNoI don't know

Please certify the following:

By checking this box I certify that it has been at least 2 months since my last COVID-19 related vaccination.

Live Vaccines (MMR) Please answer the following:

	Yes	No	Don't Know
Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem? Have you been diagnosed with rheumatoid arthritis, ankylosing spondylitis, or Crohn's disease?
In the past 3 months, have you taken medications that weaken your immune system such as cortisone, prednisone, other steroids or anticancer drugs, or have you had radiation treatments?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamme) globulin or antiviral drug (including acyclovir, famciclovir, valacyclovir)?
Have you received any vaccinations or skin tests in the past 4 weeks?

Have you ever had pneumonia vaccine before?

YesNoI don't know

If Yes, which pneumonia vaccine did you receive?

Prevnar 20Pneumovax 23Prevnar 13

Years since last pneumonia vaccine:

Have you ever had the shingles vaccine before?

YesNoI don't know

If Yes, which dose did you receive?

First DoseSecond Dose

Years since last shingles dose:

I have no insurance

Prescription Insurance Card

RxBIN #

PCN #

ID #

Rx Group #

Note: If you have a Medicare Part A and B card (commonly issued to those 65 or older), please provide Medicare Part B Number or the last 4 digits of your SSN.

Medicare Number (from red & blue card)

OR Last 4 of your SSN

This field is optional and recommended for those who do not know their Medicare Part B number.

Primary Care Provider's Name

Primary Care Provider Phone

Primary Care Provider Address

Address

Street Address Line 2

CityState

Zip

Please select your race (you can select multiple options)*

Please select your ethnicity*

1 - Hispanic2 - Not Hispanic or Latino3 - Unknown

I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have either received or been provided access to the relevant Vaccine Information Sheet(s). I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless V-Care Pharmacy, its subsidiaries, divisions, afiiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s I certity that I am at least 18 years old and hereby give my consent to the qualified pharmacy personnel of V-Care Pharmacy to administer the vaccine(s). If under 18 years old, signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation when required.

Name (Print)*

Date*

Date

Patient Signature (Parent/Legal Guardian if minor)*

Please

Vaccine Administration Record

Insurance Information

Primary Healthcare Provider Information

State Immunization Reporting

Consent