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Kohlls Rx

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402-408-1990 / 866-500-7800
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You are here: Home / COVID-19 Information / COVID-19 Vaccinations at Kohll’s Rx / COVID-19 Vaccination Consent & Release Form: Malvern

COVID-19 Vaccination Consent & Release Form: Malvern

Read the Frequently Asked Questions about the COVID-19 vaccines:

  • Pfizer (12+) Fact Sheet for Recipients/Caregivers – updated 11-19-2021
  • Pfizer (5-11) Fact Sheet for Recipients/Caregivers – updated 10-29-2021
  • Moderna Fact Sheet for Recipients/Caregivers – updated 11-19-2021
  • Janssen Fact Sheet for Recipients/Caregivers – updated 11-19-2021

UPDATE: A 4th vaccine dose has been approved for immunocompromised people.

NOTE: Only Iowa Residents are eligible for vaccinations at our MALVERN, IA location.

  • Vaccine Selection

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  • Effective 03/29/22: 2nd booster doses are currently approved for patients 50 years and older or those 12 and older with a solid organ transplant or similar level of immunocompromise.

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  • Vaccination Status

  • Remember, you'll need to schedule your second dose (booster) a minimum of 28 to 42 days from your first dose. Please schedule this second dose (booster) by clicking the same link and answering the same questions you used for your first dose appointment.
  • NOTE: Be sure to bring your COVID-19 vaccine card to your appointment.
  • Booster Shot Qualifications

    Pfizer

    Pfizer booster doses may be given at least 5 months after the initial two-dose series for those 12 and older.

    Moderna

    Moderna booster doses may be given at least 6 months after the initial two-dose series for those 18 and older.

    Janssen (Johnson & Johnson)

    Booster doses of Janssen may be given at least 2 months after the original dose for all patients 18 and older.

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  • Additional Questions for Pfizer Recipients

  • NOTE: Pfizer 3rd dose is available to patients who are immunocompromised. Pfizer booster dose is available to patients 65 years and older or patients 18-64 with underlying medication conditions.

    • - Cancer
    • - Chronic kidney disease
    • - Chronic lung diseases: (COPD, moderate to severe asthma, interstitial lung disease, cystic fibrosis, and pulmonary hypertension), dementia, alzheimers, diabetes, down syndrome
    • - Heart conditions (heart failure, coronary artery disease, cardiomyopathies or hypertension)
    • - HIV
    • - Immunocompromised: (high dose oral steroids, injections or infusions that lower your immune system)
    • - Liver disease
    • - Overweight & obese: BMI 25 kg/m2 or greater
    • - Pregnant or less than 42 days postpartum
    • - Sickle cell disease or thalassemia
    • - Smoker
    • - Former smoker
    • - Solid organ or blood stem cell transplant
    • - Stroke or cerebrovascular disease
    • - Substance use disorder: alcoholic, addicted to opioids
    • - Cancer
    • - Chronic kidney disease
    • - Chronic lung diseases: (COPD, moderate to severe asthma, interstitial lung disease, cystic fibrosis, and pulmonary hypertension), dementia, alzheimers, diabetes, down syndrome
    • - Heart conditions (heart failure, coronary artery disease, cardiomyopathies or hypertension)
    • - HIV
    • - Immunocompromised: (high dose oral steroids, injections or infusions that lower your immune system)
    • - Liver disease
    • - Overweight & obese: BMI 25 kg/m2 or greater
    • - Pregnant or less than 42 days postpartum
    • - Sickle cell disease or thalassemia
    • - Smoker
    • - Former smoker
    • - Solid organ or blood stem cell transplant
    • - Stroke or cerebrovascular disease
    • - Substance use disorder: alcoholic, addicted to opioids
  • This applies to Healthcare Worker and Non-Medical Personnel working within the confines of an institution treating patients. (Secretary, sanitation worker, kitchen staff, etc. working in a hospital, urgent care, doctor’s office, etc.)
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  • Additional Questions for Moderna Recipients

  • Booster Notifications

  • ELIGIBLE: You have been approved by the FDA to receive a third dose of COVID-19 vaccine. Please continue completing the rest of this form.
  • NOT ELIGIBLE: You have not been approved by the FDA to receive any additional dose of COVID-19 vaccine at this time.
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  • Appointment Scheduling

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  • NOTE: Minors under the age of 18 have not been approved by the FDA to receive a third dose of COVID-19 vaccine.
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  • Your Information

  • We are able to vaccinate individuals who are 18 or older at this location. Our Millard and Papillion locations are able to vaccinate individuals who are 16 and older.
  • NOTICE:

    Only IOWA residents are eligible for vaccinations at our Malvern, IA location. If you are NOT an Iowa resident and eligible for a vaccine in Nebraska, please make an appointment at one of our Nebraska locations.

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  • Parent / Guardian Information

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  • Minor Information

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  • Insurance Information

    Your insurance is required to pay 100% of your vaccination. Contact your insurance company if they do not cover the charges.
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  • Identification Information

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  • Insurance Card Images

    If you have any type of Medicare plan, please upload an image of your Red White and Blue Medicare card.
  • Accepted file types: jpg, jpeg, gif, tif, tiff, pdf, png, bmp.
  • Accepted file types: jpg, jpeg, gif, tif, tiff, pdf, png, bmp.
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  • Medical History Information

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  • Consent & Signature

  • I understand that at this time, the COVID-19 Moderna vaccine requires 2 doses given 28 days apart. If this is my second dose, I will bring my vaccine card with me to be completed (recommended but not required).
  • I agree to follow the recommended 15-minute observation period or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
  • I have read the above information or have had the information explained to me. I have had a chance to ask questions and these have been answered to my satisfaction. I understand the benefits and the risks of the Covid-19 vaccine and ask that the vaccine is given to me, or to the person named above for whom I am authorized to make this request. I accept responsibility for seeking medical attention for any problems with this vaccination. I authorize billing the administration fee to my healthcare insurance.
  • Signature must be a parent/guardian's if the vaccine recipient is a minor.

Kohll's Pharmacy & Homecare'

Kohll's has been serving patients in Omaha, Lincoln and western Iowa since 1948. We provide high-quality service to better your health.

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Locations:

Do you have COVID-19 questions? Use our Contact Form to receive the quickest response.

Call 402-973-1947 for our COVID-19 team.

  • 2915 Leavenworth St / 402-342-6548
  • 12741 Q St / 402-895-3102
  • 5002 Dodge St / 402-553-8901
  • 808 N 27th St (Lincoln) / 402-476-3342
  • 403 Main St (Malvern) / 712-624-9050
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