Price Chopper #06 Vaccine Appointment Form

Price Chopper #06: 7600 State Ave, Kansas City, KS - Vaccine Appointment Form
COVID-19 vaccinations are available at no cost to anyone living in the United States.
- Please bring your pharmacy insurance or Medicare Part B card if insured. If you do not have insurance, please bring a form of ID such as state ID, driver's license, passport, visa, social security number, or other.
- If you are getting a second or third dose of the COVID vaccine, please remember to bring your vaccine record card.
- All people getting a COVID-19 vaccine will need to stay in the vaccine area for 15 minutes after the shot is given.
- Please bring your pharmacy insurance or Medicare Part B card if insured to your vaccine appointment.
  - Part B may not pay for COVID-19 vaccines until mid-September 2024
- Those who do not have insurance will be asked to pay a cash price for their vaccine(s).
I need to schedule:*

COVID-19, Moderna (12+years)Hepatitis A/BHPVMeningococcalMMR (Measles/Mumps/Rubella)PneumoniaRSVShinglesTetanus/Diphtheria/Pertussis (Tdap)
COVID-19 Vaccine appointments are full at this time. As soon as we receive more vaccine, appointments will re-open. Thank you for understanding!
Appointment*
Vaccine Recipient Information
Name*

First NameMiddle NameLast Name
Age of person receiving vaccine: Age*years old
Phone Number*
Please enter a valid phone number.
Phone Type*
Email - will receive confirmation of appointment*
example@example.com
Name of Person Completing This Form (if not the Vaccine Recipient listed above):
Full Name
Relationship to Patient (if not the Vaccine Recipient):
Full Name
Should be Empty:

Price Chopper #06: 7600 State Ave, Kansas City, KS - Vaccine Appointment Form

Vaccine Recipient Information