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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.

Fill out online form below
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.
Vaccines Requested*
- Shingles (Shingrix) - recommended at age 50
- Pneumonia - recommended at age 65
- Hepatitis A
- Hepatitis B
- Tetanus (Tdap) - recommended every 10 years
- MMR
- HPV
- Meningitis
- Rabies immune globulin and vaccine (Available only at Q STREET and LINCOLN locations)
Body Weight*
Please include pounds or kilograms in the weight.
IMPORTANT: You will be contacted by Kohll's Rx staff once the rabies immune globulin and vaccine are available for you.
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.
Date Format: MM slash DD slash YYYY
Pneumonia Vaccine Preference*
- Prevnar 13
- Pneumovax 23
- I'm not sure (pharmacist will recommend)
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.
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)
Preferred Date To Receive Vaccination - Midtown*
For the shortest wait time when you arrive for your appointment, please choose a date and time at least 6 hours from now so our pharmacists have time to process your information before you arrive.
Date Format: MM slash DD slash YYYY
Preferred Date To Receive Vaccination - Downtown*
For the shortest wait time when you arrive for your appointment, please choose a date and time at least 6 hours from now so our pharmacists have time to process your information before you arrive.
Date Format: MM slash DD slash YYYY
Preferred Date To Receive Vaccination - Millard*
For the shortest wait time when you arrive for your appointment, please choose a date and time at least 6 hours from now so our pharmacists have time to process your information before you arrive.
Date Format: MM slash DD slash YYYY
Preferred Date To Receive Vaccination - Lincoln*
For the shortest wait time when you arrive for your appointment, please choose a date and time at least 6 hours from now so our pharmacists have time to process your information before you arrive.
Date Format: MM slash DD slash YYYY
Preferred Date To Receive Vaccination - Malvern*
For the shortest wait time when you arrive for your appointment, please choose a date and time at least 6 hours from now so our pharmacists have time to process your information before you arrive.
Date Format: MM slash DD slash YYYY
Preferred Appointment Time - Midtown*
Preferred Appointment Time - Downtown*
Preferred Appointment Time - Millard*
Preferred Appointment Time - Papillion*
Preferred Appointment Time - Lincoln*
Preferred Appointment Time - Malvern*
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
- NO
Do you have Medicare Part B (medical)?*
- YES
- NO
Release & Consent
1: Are you sick today?*
- YES
- NO
2: Do you have allergies to medications, food, a vaccine component, or latex?*
- YES
- NO
3: Have you ever had a serious reaction after receiving a vaccine?*
- YES
- NO
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
- NO
5: Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?*
- YES
- NO
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
- NO
7: Have you had a seizure or a brain or other nervous system problem?*
- YES
- NO
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
- NO
9: Have you ever had Guillain-Barre syndrome?*
- YES
- NO
10: Have you received any vaccine in the last 4 weeks?*
- YES
- NO
Are you currently pregnant, lactating, or could become pregnant in the next month?*
- YES
- NO
Have you had a mastectomy?*
- YES
- NO
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?*
- Online Search
- Facebook
- Newspaper
- Word Of Mouth
- Phone Call
- Radio
- Email
- Text
Phone
This field is for validation purposes and should be left unchanged.

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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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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