If you have not made an appointment yet, please do so before filling out this form. Schedule an Appointment

General Info

Make sure to bring a copy of your insurance card to your appointment.
Left/Right Deltoid is the most common choice.

Release of Information / Assignment of Insurance Benefits

I believe I understand the benefits and risks of the vaccine I have selected and ask that the vaccine be given to me or to the person named above for whom I am authorized to make this request. Under HIPAA provisions, I authorize the release of information about my immunization status and health status for continuing health services only which may include my referring physician or other health care agencies assigned to my care. All health information provided is held in strict confidence, following HIPAA regulations. I acknowledge receipt of Notice of Privacy Practices from Yorkville Pharmacy. Medicare or 3rd party patients: I do herby authorize Yorkville Pharmacy to release information and request payment for immunization services. I certify that the information given by me in applying for payment under Medicare or any 3rd party is correct. I authorize release of all records to act on this request. I request that payment of authorized benefits be made on my behalf. Should any information provided prove incorrect, thus denying payment, I personally guarantee payment for services rendered on my behalf and may be billed accordingly.

Immunization Screening

If you have received a dose of COVID-19 vaccine, please answer all of the following that apply.
  • It has been at least 28 days after completion of the initial series.
  • I have made an appointment to get the same vaccine product as the initial two-dose mRNA COVID-19 vaccine series (Pfizer-BioNTech or Moderna).
  • I am attesting that I meet the following criteria of being immunocompromised below.

Currently, CDC is recommending that moderately to severely immunocompromised people receive an additional dose. This includes people who have:
  • Active treatment for solid tumor and hematologic malignancies
  • Receipt of solid-organ transplant and taking immunosuppressive therapy
  • Receipt of CAR-T-cell or hematopoietic stem cell transplant (within 2 years of transplantation or taking immunosuppression therapy)
  • Moderate or severe primary immunodeficiency (e.g., DiGeorge syndrome, Wiskott-Aldrich syndrome)
  • Advanced or untreated HIV infection
  • Active treatment with high-dose corticosteroids (i.e., ≥20mg prednisone or equivalent per day), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor-necrosis (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory.
[note: monoclonal antibodies does not include antibiotics that would be prescribed to you and filled at a pharmacy]

I agree to be vaccinated today. I have received and understand information about the vaccine or vaccines I will receive. I have had my questions answered to my satisfaction. I authorize the provider performing this service to release to and access from my insurer (if applicable) and primary health care provider any medical or other information necessary. I authorize the payment of medical benefits to the provider performing this service.
Consent (check each box below after reading and signing):
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (J&J EUA Fact Sheet, Moderna EUA Fact Sheet, Pfizer Age 12+ EUA Fact Sheet, Pfizer Age 5-11 EUA Fact Sheet, Novavax Fact Sheet), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I understand that I may be given a COVID-19 vaccine that requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my first dose of the COVID-19 vaccine and it is 2 dose series, I intend to receive a second dose of the same vaccine in accordance with the timeframe specified in the Fact Sheet to complete the vaccination series.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.

Please bring proof of eligibility to get the vaccine with you to your appointment.(ie, Id, work badge, meds to prove you fit in the current phase. You will be denied if you do not qualify for the current phase of vaccination approved by the state.

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