Vaccination Consent Form

NOTE: If you have not yet booked an appointment time for your vaccination at Kohll's Rx, please start by visiting https://kohllsrx.simplybook.me/ to make your appointment.

Reserve Your Appointment Now

Vaccination Location

Please mark the location below that you selected when scheduling your appointment.

Appointment Location(Required)

Omaha - Downtown: 2915 Leavenworth Street

Omaha - Midtown: 5002 Dodge Street

Omaha - Millard: 12741 Q Street

Lincoln, NE: 808 N 27th Street

Malvern, IA: 403 Main Street

Vaccine Selection: Omaha - Downtown(Required)

In order for us to collect the required information for your appointment, please indicate which vaccination(s) you chose when booking your appointment. If you are unable to select that vaccination, it may not currently be available at that pharmacy location.

Vaccine Selection: Omaha - Midtown(Required)

Vaccine Selection: Omaha - Millard(Required)

Vaccine Selection: Lincoln, NE(Required)

Vaccine Selection: Malvern, IA(Required)

Influenza (Flu) Vaccine

Influenza Vaccine Preference(Required)

Standard (okay for any age)

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

High Dose / Adjuvanted (≥ 65 years of age or immunosuppresed only)

Nasal (Flu-Mist) (2-49 years old) - Millard location only (134 spots left)

COVID-19 Vaccine

COVID-19 Vaccine Preference: Omaha - Downtown(Required)

Moderna (12 years and older)

Pfizer (12 years and older)

COVID-19 Vaccine Preference: Omaha - Midtown(Required)

Moderna (12 years and older)

Pfizer (12 years and older)

COVID-19 Vaccine Preference: Omaha - Millard(Required)

Pfizer (6 months to 4 years)

Pfizer (5 years to 11 years)

Pfizer (12 years and older)

Moderna (6 months to 11 years)

Moderna (12 years and older)

Novavax (12 years and older)

COVID-19 Vaccine Preference: Lincoln, NE(Required)

Moderna (12 years and older)

Moderna (6 months to 11 years) (0 spots left)

Pfizer (12 years and older)

COVID-19 Vaccine Preference: Malvern, IA(Required)

Moderna (12 years and older)

Pfizer (12 years and older)

When was your last COVID-19 vaccine?(Required)

NOTE: Please ensure you bring your COVID-19 vaccine card with you to your appointment so staff can verify your vaccine history and document the new vaccine.

MPox Vaccine

Is this your 1st or 2nd dose of Jynneos?(Required)

First

Second

Eligibility criteria for vaccination:(Required)

All of the criteria below must be selected to be eligible per CDC guidelines.

18 years of age or older

have sexual risk factors for mpox

have not been diagnosed with mpox during the ongoing outbreak

have not already received 2 doses of the JYNNEOS vaccine

Pneumonia Vaccine

Pneumonia Vaccine Preference(Required)

Prevnar 20

Prevnar 23

Unsure (Pharmacist’s Recommendation)

Have you received a pneumonia vaccine before?(Required)

YES

UNSURE

When was your last pneumonia vaccine?(Required)

What pneumonia vaccine formulation did you last receive?(Required)

RSV Vaccine

Are you 60 years of age or older?(Required)

Only ONE dose of RSV vaccine is recommended. Repeat doses are NOT recommended or covered by insurance.

YES

Are you pregnant and between 32 and 36 weeks of gestation?(Required)

YES

NOTE: Based on your answers to the above questions, you are not eligible for the RSV vaccine.

Shingles (Shingrix) Vaccine

Additional Shingles Vaccine Information(Required)

This is my first dose of Shingles vaccine

This is my second dose of Shingles vaccine

Hepatitis A Vaccine

Hepatitis A Vaccine Preference(Required)

This is my first dose

This is my second dose

Hepatitis B Vaccine

Hepatitis B Vaccine Preference(Required)

This is my first dose

This is my second dose

This is my third dose

Meningitis Vaccine

Meningitis Vaccine Preference(Required)

Meningococcal A,C,Y,W (Menactra, Menveo, MenQuadfi)

Meningococcal B (Bexsero)

BOTH Meningococcal A,C,Y,W & Meningococcal B

Unsure (Pharmacist’s Recommendation)

Your Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Date of Birth(Required)

Sex(Required)

FEMALE

MALE

Primary Care Physician(Required)

Insurance Information

What kind of Insurance do you have?(Required)

Commercial / Regular Health Insurance

Medicare

Medicaid

Tricare

Kohll’s Rx Corporate Voucher (0 spots left)

Uninsured - Payment required at time of appointment.

Medicare Type(Required)

Traditional Medicare (Part A and B) and Drug Plan (Part D)

Medicare Advantage (Part C)

Medicare Beneficiary ID(Required)

Medicaid ID(Required)

Sponsor's SSN(Required)

Which managed care plan do you have?(Required)

Total Care

UHC

Healthy Blue

Molina

BIN

PCN

Rx Group

Pharmacy Insurance Card

Please ensure your card has pharmacy billing information on it - which includes Rx BIN, Rx PCN, Rx Group, etc.

Drop files here or

Accepted file types: jpg, jpeg, gif, tif, tiff, pdf, png, bmp, Max. file size: 20 MB, Max. files: 1.

Medicare Card

Please scan your red, white, and blue Medicare card if you have one. This is commonly required for billing certain vaccines.

Drop files here or

Accepted file types: jpg, jpeg, gif, tif, tiff, pdf, png, bmp, Max. file size: 20 MB, Max. files: 1.

Medicaid Card

If available, please scan your state Medicaid card.

Drop files here or

Accepted file types: jpg, jpeg, gif, tif, tiff, pdf, png, bmp, Max. file size: 20 MB, Max. files: 1.

Your Health

Are you sick today?(Required)

YES

Do you have allergies to medications, food, a vaccine component, or latex?(Required)

YES

Have you ever had a serious reaction after receiving a vaccine?(Required)

YES

Do you have cancer, leukemia, HIV/AIDS, or any other immune system problem?(Required)

YES

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?(Required)

YES

Have you had a seizure or a brain or other nervous system problem?(Required)

YES

During the past year, have you received a transfusion of blood or blood products, or been given immune globulin or an antiviral drug?(Required)

YES

Have you ever had Guillain-Barre syndrome?(Required)

YES

Have you received any vaccines in the last 4 weeks?(Required)

YES

Are you currently pregnant, lactating, or expecting to be pregnant in the next few months?(Required)

YES

Have you had a mastectomy?(Required)

YES

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Consent

Questions or Comments

Signature

Untitled

First Choice

Second Choice

Third Choice

Vaccination Consent Form