GLCP Vaccine Sign Up

Grass Lake Community Pharmacy Vaccine Appointment Sign Up

Vaccine Sign up for Covid-19, Flu Shot, Pneumonia, HepA, HepB, or Shingles. Two vaccines can be given in one appointment.
Appointment
Name

First NameLast Name
Date of Birth

MonthDayYear
Name of Parent or Guardian
Gender
Email

Confirmation EmailWe ask everyone to confirm their email address in hopes to ensure they will receive their confirmation email for their appointment(s).
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Race
Ethnicity
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select What Vaccine(s) You Wish To Receive (Maximum of 2 Vaccines per Appointment)
What Vaccine(s) Do You, Or Your Child, Need?
COVID-19 Vaccine: Select What Vaccine & Type You Wish To Receive
FLU Vaccine: Select the flu vaccine you wish to receive
PNEUMONIA Vaccine: Select the vaccine you wish to receive
HEPATITIS Vaccine: Select the vaccine you wish to receive
SHINGLES Vaccine: Select which dose you wish to receive
OPTIONAL Upload Section

OPTIONAL UPLOADS SPEED UP APPOINTMENTS: upload photo IDs, prescription insurance, and Medicare cards to speed up your appointment. In case something is missed, or uploaded blurry, please bring these documents with you to your appointment.
Please Upload Your Drivers License or Photo ID

This is an OPTIONAL field & can submit this form without uploading anything in this field. For those who do upload their license/ID please ensure all the information on the card uploaded is CLEAR. If we CANNOT READ the information on the card, we may need to reach back out to you in order to collect that information.
Cancelof
Please Upload Your Prescription Insurance Card, Ensure the "Rx" Symbol is on the Uploaded Card

This is an OPTIONAL field & form can be submitted without uploading anything in this field. For those who do upload their Prescription Insurance Card please ensure the information on the card(s) uploaded is legible. If we cannot read the information on the insurance card, we may need to reach back out to you in order to collect that information.
Cancelof
If Applicable: Please Upload Your Medicare Card

This is an OPTIONAL field & form can be submitted without uploading anything in this field. For those who do upload their Medicare Card please ensure the information on the card uploaded is legible. If we cannot read the information we may need to reach back out to you in order to collect that information.
Cancelof
General Vaccine Questions

Please Answer The Following Questions For Our Pharmacist
1. Do you, or your child, have ANY Allergies to a Vaccine Component being received, OR LATEX?
2. Have you, or your child, had a Serious ALLERGIC REACTION to a VACCINE in the past?
3. Have you, or your child, had a Serious ALLERGIC REACTION to ANYTHING in the past Such as medication, food, bees, etc.?
4. Have you, or your child, ever had Guillain-Barre' Syndrome?
5. Have you, or your child, ever had Cancer, Leukemia, HIV/AIDS, or any other immune system problem that your doctor may advise you, or your child, to avoid the vaccination?
6. In the past 3 months, have you, or your child, taken medication that has weakened the immune system, such as Cortisone, Prednisone, other Steroids, Anticancer Drugs, or had Radiation treatments?
7. Are you immunocompromised?
For Those Receiving A FLU SHOT: Do You, Or Your Child, Have An Allergy to EGGS or Components of The Influenza Vaccines?
I Accept & Acknowledge That
Signature of ADULT client or PARENT/GUARDIAN if a MINOR is being vaccinated
Vaccine Administered, Lot Number, Expiration Date
Is the client sick today, or have a fever?
Location of FIRST Intramuscular Administration FLU
Location of *SECOND* Intramuscular Administration COVID-19
Pharmacist Signature
Notes about this vaccination/visit/billing (please initial and date your entry)
Should be Empty:

Grass Lake Community Pharmacy Vaccine Appointment Sign Up

Select What Vaccine(s) You Wish To Receive (Maximum of 2 Vaccines per Appointment)

OPTIONAL Upload Section

General Vaccine Questions