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Kohlls Rx

Locally owned and operated since 1948.

402-408-1990 / 866-500-7800
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You are here: Home / Pharmacy / Vaccines & Flu Shots / Express Lane Vaccination Sign Up Form

Express Lane Vaccination Sign Up Form

Get the fastest, safest vaccination experience.

  1. Fill out online form below
  2. Choose your preferred appointment date and time.
  • Vaccines Available

    To learn more about vaccines in relation to COVID-19 and receiving more than one vaccine at a time, click here.
  • Please enter the date you received your first dose of Shingles vaccine.
    Date Format: MM slash DD slash YYYY
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  • Your Information

  • Your immunization record will be faxed to the listed physician.
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  • Appointment Scheduling

    Vaccination appointments are available during our regular business hours at all Kohll's Rx locations. To view our current locations and hours, click here.
  • Testing is available on a first-come, first-served basis and our testing hours are updated regularly.
  • Testing is available on a first-come, first-served basis and our testing hours are updated regularly.
  • Testing is available on a first-come, first-served basis and our testing hours are updated regularly.
  • Testing is available on a first-come, first-served basis and our testing hours are updated regularly.
  • Testing is available on a first-come, first-served basis and our testing hours are updated regularly.
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  • Insurance Information

    Please provide your current insurance and Medicare information, and be sure to bring your insurance cards with you at the time of your appointment.
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  • Release & Consent

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  • Consent, Comment, and Signature

  • 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 and ask that the vaccine(s) is/are 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 for the vaccine and its administration to my insurance company and agree to pay any remaining cost up front. I agree to stay in the vaccine administration
    area for 15 minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
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  • This field is for validation purposes and should be left unchanged.