Vaccine COVID AND RSV ARE CURRENTLY APPOINTMENT ONLY AND THEY ARE IN THEIR OWN CATEGORY BELOW. WE ANTICIPATE INCREASING CAPACITY AS STAFFING AND SUPPLY ALLOW. Intake Vax First Name * M.I. Middle Initial Last Name * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Date of Birth * Home Phone Cell Phone Email * Store * Oak HarborClintonLa Conner Drug Allergies * No Known Drug Allergies Penicillin Codeine Erythromycin Aspirin Peanuts Sulfa Antibiotic OtherOther OtherOther OtherOther Medical Conditions * No Known Medical Conditions High Blood Pressure Diabetes (Type 1) Diabetes (Type 2) High Cholesterol Asthma Epilepsy Arthritis Depression Headaches Glaucoma Smoking Pregnancy (type due date ->)Pregnancy (type due date ->) Breastfeeding OtherOther OtherOther OtherOther OtherOther Insurance? * yesno Insurance Card Side 1 * Drop a file here or click to upload Choose File Maximum upload size: 516MB Insurance Card Side 2 * Drop a file here or click to upload Choose File Maximum upload size: 516MB Vaccine Influenza (Flu) QuadHigh Dose Influenza (Flu) 65yr +Recombinant Zoster (Shingles aka Shingrix)Tdap (Tetanus, Diphtheria, Pertussis) BoostrixPREVNAR 20 (Pneumococcal 20-valent Conjugate Vaccine)PREVNAR 13Ⓡ (Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein])Havrix (Hepatitis A)Engerix (Hepatits B)Measles/Mumps/Rubella (MMR)Meningococcal BTyphoidGardasil (HPV)Pneumococcal Polysaccharide Vaccine (PPSV23) Vaccine2 Influenza (Flu) QuadHigh Dose Influenza (Flu) 65yr +Recombinant Zoster (Shingles aka Shingrix)Tdap (Tetanus, Diphtheria, Pertussis) BoostrixPREVNAR 20 (Pneumococcal 20-valent Conjugate Vaccine)PREVNAR 13Ⓡ (Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein])Havrix (Hepatitis A)Engerix (Hepatits B)Measles/Mumps/Rubella (MMR)Meningococcal BTyphoidGardasil (HPV)Pneumococcal Polysaccharide Vaccine (PPSV23)VAXNEUVANCE™ (Pneumococcal 15-valent Conjugate Vaccine) Vaccine Appt Req 1 Pfizer COVID (Comirnaty) ApptReqModerna COVID (Spikevax) ApptReqRSV (ABRYSVO by Pfizer) ApptReq COVID & RSV are located in this dropdown menu Vaccine Appt Req 2 Pfizer COVID (Comirnaty) ApptReqModerna COVID (Spikevax) ApptReqRSV (ABRYSVO by Pfizer) ApptReq Appointment Oak Harbor * Appointment Clinton * Appointment La Conner * Date To Be Vaccinated * When do you plan on coming in to get this vaccine? Are you getting a Covid-19 Shot As Well? YesNo If Yes, a separate appointment needs to be made at https://islanddrug.com/appt Please include your last dose of this vaccine or any other details relevant to it’s administration including any other vaccines taken recently I will review Vaccine Information Sheet corresponding to the selected vaccine in the email received after submitting this form, and/or have had explained to me the information on the sheet about the vaccine. prior to injection. I have had the chance to ask questions and they were answered to my satisfaction. I believe I understand the benefits/risk of the vaccine and ask that it is given to me or the person named above for whom I am authorized to make this request. I am aware of the pharmacy’s policy that billing my insurance/Medicare on my behalf is a courtesy provided by them and that I am responsible for any deductible or co-insurance amounts. I understand that Medicare may pay part of the amount billed by the pharmacy or part of Medicare’’ allowable amount whichever is less and that I am responsible for the remaining amount. Also, I understand that if any of my claims are rejected by my insurance/Medicare, I will pay the pharmacy for the full amount of the claim. I recognize my obligation to forward payment to the pharmacy for any payment received by me due to them. INSURANCE LIFE-TIME AUTHORIZATION:I request payment under the medical insurance program be made to me or the provider names above on any bills for service. I authorize the above named provider to release to the Social Security Administration or its intermediaries or carriers any information needed for this claim or any related Medicare claim. I further permit a copy of this authorization to be used in the place of the original. If for some reason, the patient is mentally or physically unable to sign this card, the signature of a relative, friend, legal guardian, representative payee, or the representative of any institution providing care is acceptable. The name of the patient should be shown on the signature line followed by “BY”, and the signature and address of the individual signing for the patient. The mental or physical problem, which does not allow the patient to sign, and the relationship of the person signing on their behalf, must also be indicated on this card. A physician or supplier’s office cannot sign on behalf of a patient except under extraordinary circumstances. Please contact the Medicare Office if you need further details. I also received the Notice of Privacy Practices. Office use:DATE OF VACCINATION:________________ Signature of Administrator:_____________________ MNF:____________________LOT#_________________EXP DATE:______________________ SITE OF INJECTION: R OR L Deltoid High Dose? We saw you chose the regular Quadrivalent flu shot, but at >64 yrs of age you are eligible for the ‘High Dose’ version, want to change? Signature Confirming the Fine Print Statement * Clear If you are human, leave this field blank. Submit Δ Share this:TwitterFacebookLike this:Like Loading...