Fiesta MLK Pharmacy - COVID-19 Vaccination Appointments

COVID-19 Vaccination Appointment ---1st Dose Only---
Current Patient of Fiesta MLK Pharmacy?
Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Insurance Type?
Medicare Number (MBI from Red, While and Blue card)
Example: 1EG4-TE5-MK72
Insurance Information (Member ID, BIN, PCN and Group from the card)
Example: Member ID - EQW121323232,Rx BIN - 004336, PCN - PDMX, Group - RX 04343
State ID Information (Uninsured / Other)
Please provide issuing state name and ID number
Appointment
Are you able to stop by with a short notice (30 - 60 mins), should a vaccine becomes available earlier than your appointment time?
Please complete the Vaccine Consent Form before your appointment to reduce your wait time at the Pharmacy:
https://hipaa.jotform.com/fiestamlkpharmacy/covid19-vaccine-consent-form
Should be Empty:

COVID-19 Vaccination Appointment ---1st Dose Only---