Express Lane Vaccination Sign Up Form

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Vaccines Available

To learn more about vaccines in relation to COVID-19 and receiving more than one vaccine at a time, click here.

Vaccines Requested*

Additional Shingles Vaccine Information*

This is my first dose of Shingles vaccine

This is my second dose of Shingles vaccine

First Shingles Vaccine Date*

Please enter the date you received your first dose of Shingles vaccine.

Pneumonia Vaccine Preference*

Prevnar 20

Pneumovax 23

I'm not sure (pharmacist will recommend)

Influenza Vaccine Preference*

Standard Quadrivalent

"Egg-Free" (Cell-Based or Recombinant)

High Dose (≥ 65 years of age only)

Unsure (Pharmacist’s Recommendation)

Meningitis Vaccine Preference*

Meningococcal A,C,Y,W (Menactra)

Meningococcal B (Bexsero)

I'm not sure (pharmacist will recommend)

Your Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP

Email*

Enter Email Confirm Email

Phone

Date of Birth*

Sex*

Male

Female

Primary Care Physician

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.

Preferred Kohll's Location To Receive Vaccination*

5002 Dodge Street (Omaha, NE)

2915 Leavenworth St. (Omaha, NE)

12741 Q Street (Omaha, NE)

808 N 27th St. (Lincoln, NE)

403 Main Street (Malvern, IA)

When would you like to schedule your vaccination? - Midtown*

Appointments are available on a first-come, first-served basis and our hours are updated regularly.

Choose your Monday, August 1 appointment time:*

Choose your Tuesday, August 2 appointment time:*

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When would you like to schedule your vaccination? - Downtown*

Appointments are available on a first-come, first-served basis and our hours are updated regularly.

Choose your Monday, August 1 appointment time:*

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When would you like to schedule your vaccination? - Millard*

Appointments are available on a first-come, first-served basis and our hours are updated regularly.

Choose your Monday, August 1 appointment time:*

Choose your Tuesday, August 2 appointment time:*

Choose your Wednesday, August 3 appointment time:*

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Choose your Monday, October 17 appointment time:*

When would you like to schedule your vaccination? - Lincoln*

Appointments are available on a first-come, first-served basis and our hours are updated regularly.

Choose your Monday, August 1 appointment time:*

Choose your Tuesday, August 2 appointment time:*

Choose your Wednesday, August 3 appointment time:*

Choose your Thursday, August 4 appointment time:*

Choose your Friday, August 5 appointment time:*

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When would you like to schedule your vaccination? - Malvern*

Appointments are available on a first-come, first-served basis and our hours are updated regularly.

Choose your Monday, August 1 appointment time:*

Choose your Tuesday, August 2 appointment time:*

Choose your Wednesday, August 3 appointment time:*

Choose your Thursday, August 4 appointment time:*

Choose your Friday, August 5 appointment time:*

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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.

What kind of insurance do you have?*

Commercial / Regular Health Insurance

TRICARE

Kohll's Rx Corporate Voucher

Managed Care Medicare

Traditional Medicare

I do not have insurance

Insurance Provider*

Medicare Insurance Provider*

Patient ID #*

Sponsor's SSN*

Rx Group #*

Bin #*

Processor # (PCN)*

Medicare #*

Is this a Medicare HMO/Advantage Plan?*

YES

Do you have Medicare Part B (medical)?*

YES

Release & Consent

1: Are you sick today?*

YES

2: Do you have allergies to medications, food, a vaccine component, or latex?*

YES

3: Have you ever had a serious reaction after receiving a vaccine?*

YES

4: Do you have a long-term health problem with heart, lung, kidney, or metabolic disease (e.g. diabetes), asthma, a blood disorder, no spleen, complement component deficiency, a cochlear implant, or a spinal fluid leak?*

YES

5: Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*

YES

6: In the past 3 months, have you taken medications that affect your immune system, such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease, or psoriasis; or have you had radiation treatment?*

YES

7: Have you had a seizure or a brain or other nervous system problem?*

YES

8: During the past year, have you received a transfusion of blood or blood products, or been given immune globulin or an antiviral drug?*

YES

9: Have you ever had Guillain-Barre syndrome?*

YES

10: Have you received any vaccine in the last 4 weeks?*

YES

Are you currently pregnant, lactating, or could become pregnant in the next month?*

YES

Have you had a mastectomy?*

YES

Consent, Comment, and Signature

Consent*

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.

I agree to the following:

Comments

Patient or Guardian Signature*

Special Requests / Notes

How did you hear about us?*

Name

This field is for validation purposes and should be left unchanged.

Express Lane Vaccination Sign Up Form

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