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Home
About
Reviews
Services
VFC vaccines
Adherence Packaging
Home Delivery
TennCare Diaper Request
Product
Immunization
Covid-19 Vaccine
Covid-19 Testing
Contact
Prescription Refill
New Patient
First come first serve upon availability for children UNDER the age of 2.
Click here for Diaper Request Form
Transfer Prescription
Submit your transfer request to Lebanon Family Pharmacy
Call the pharmacy regarding Scheduled Medications/Controlled Substances
Please enable JavaScript in your browser to complete this form.
First Name
*
Last Name
*
Date of birth
*
Phone Number
*
Street Address
*
Street Address1
City
*
State
*
Zip Code
*
Email
Transfer all of my medications
*
Yes
No
Pharmacy Information
Pharmacy Phone
How many medication do you need to transfer?
*
- Please select -
1
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Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Medication Name
Rx Number
Message
I agree to the
Terms and Conditions
and
Privacy Policy
Submit Transfer
Moderna COVID-19 Vaccine Consent Form
PLEASE WEAR A MASK FOR THE APPOINTMENT
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 7
Do you qualify to receive the COVID-19 Vaccine (minimum age of 12)?
*
Yes
No
Which dose will this be for you?
*
First
Second (Must be 28 days after your 1st dose)
Third: (must be a minimum of 28 days after second dose, immunocompromised patients, 18 years of age or older)
Fourth: (must be a minimum of 3 months after 3rd dose, immunocompromised patients, 18 years of age or older: HIV, cancer, immunosuppressive medications, 65+ and long term care resident with provider consideration)
Booster 1: (minimum of 5 months from second dose, 12 years of age or older)
Booster 2: (minimum of 4 months from First Booster, 50 years of age or older)
Second Shot-Booster-1st shot was J&J (Mix, You received the J&J vaccine and has been 2 months since your dose, 18 years of age or older)
Third Shot-Booster-1st was J&J and 2nd shot was Pfizer (4 months since your 2nd dose, 18 years of age or older)
Next
Select an appointment time
Date
*
Time
*
Next
First Name
*
Middle Name
*
Last Name
*
Date of birth
*
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Phone Number
*
Street Address
*
Street Address1
City
*
State
*
Zip Code
*
Email
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Mother's Maiden Name
*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
*
Relationship to Emergency Contact
*
Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster Child
Stepchild
Care Giver
Other
Next
COVID-19 Vaccine Screen Questions:
The following questions will help us determine your eligibility to be vaccinated today.
1. Do you feel sick today?
Yes
No
Don't Know
2. Have you ever received a dose of COVID-19 Vaccine?
Yes
No
Don't Know
lf yes, which vaccine product did you receive?
*
Pfizer
Moderna
Janseen
Another Product
3. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
Yes
No
Don't Know
4. Have you ever had a history of allergic reaction or allergies to later, medications, food or vaccines (examples: polyethylene qlycol, polysorbate. eggs. bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)?
Yes
No
Don't Know
If Yes, Please list:
*
5. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
Yes
No
Don't Know
6. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
Yes
No
Don't Know
7. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
Yes
No
Don't Know
8. Have you received any vaccine in the last 14 days?
Yes
No
Don't Know
9. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
Yes
No
Don't Know
10. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
Yes
No
Don't Know
11. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Yes
No
Don't Know
12. Do you have a bleeding disorder or are you taking a blood thinner?
Yes
No
Don't Know
13. Are you pregnant or breastfeeding?
Yes
No
Don't Know
Next
Which arm would you like to get the injection on
*
Left Arm
Right Arm
Next
Consent (check each box below after reading and prior to signing the form)
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the state of Tennessee Department of Health (TDOH), and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed in this form.
I acknowledge that: (a) I understand the purpose/benefits of TennIIS Tennessee immunization registry and (b) TDOH will include my personal immunization information and my personal immunization information will be shared with the Centers of Disease Control (CDC) or other federal agencies.
Next
The vaccine is available to anyone who is insured. Please check the following if you have insurance.
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
Please Upload Insurance Card
*
Click or drag a file to this area to upload.
please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Please Upload Supporting Document
*
Click or drag a file to this area to upload.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Signature
*
Clear Signature
Date Signed
*
MM
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1921
1920
Submit Consent Form
Pfizer (Pediatric) COVID-19 Vaccine Consent Form
PLEASE WEAR A MASK FOR THE APPOINTMENT
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 7
Do you qualify to receive the COVID-19 Vaccine (age 5-11)?
*
Yes
No
Which dose will this be for you?
*
First
Second (Must be 21 days after your 1st dose)
Booster (Must be a minimum of 5 months from second dose)
Next
Select an appointment time
Date
*
Time
*
Next
First Name
*
Middle Name
*
Last Name
*
Date of birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
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31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Phone Number
*
Street Address
*
Street Address1
City
*
State
*
Zip Code
*
Email
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Mother's Maiden Name
*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
*
Relationship to Emergency Contact
*
Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster Child
Stepchild
Care Giver
Other
Next
COVID-19 Vaccine Screen Questions:
The following questions will help us determine your eligibility to be vaccinated today.
1. Do you feel sick today?
Yes
No
Don't Know
2. Have you ever received a dose of COVID-19 Vaccine?
Yes
No
Don't Know
lf yes, which vaccine product did you receive?
*
Pfizer
Moderna
Janseen
Another Product
3. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
Yes
No
Don't Know
4. Have you ever had a history of allergic reaction or allergies to later, medications, food or vaccines (examples: polyethylene qlycol, polysorbate. eggs. bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)?
Yes
No
Don't Know
If Yes, Please list:
*
5. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
Yes
No
Don't Know
6. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
Yes
No
Don't Know
7. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
Yes
No
Don't Know
8. Have you received any vaccine in the last 14 days?
Yes
No
Don't Know
9. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
Yes
No
Don't Know
10. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
Yes
No
Don't Know
11. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Yes
No
Don't Know
12. Do you have a bleeding disorder or are you taking a blood thinner?
Yes
No
Don't Know
13. Are you pregnant or breastfeeding?
Yes
No
Don't Know
Next
Which arm would you like to get the injection on
*
Left Arm
Right Arm
Next
Consent (check each box below after reading and prior to signing the form)
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the state of Tennessee Department of Health (TDOH), and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed in this form.
I acknowledge that: (a) I understand the purpose/benefits of TennIIS Tennessee immunization registry and (b) TDOH will include my personal immunization information and my personal immunization information will be shared with the Centers of Disease Control (CDC) or other federal agencies.
Next
The vaccine is available to anyone who is insured. Please check the following if you have insurance.
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
Please Upload Insurance Card
*
Click or drag a file to this area to upload.
please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Please Upload Supporting Document
*
Click or drag a file to this area to upload.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Signature
*
Clear Signature
Date Signed
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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2000
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1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Submit Consent Form
Pfizer COVID-19 Vaccine Consent Form
PLEASE WEAR A MASK FOR THE APPOINTMENT
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 7
Do you qualify to receive the COVID-19 Vaccine (minimum age of 12)?
*
Yes
No
Which dose will this be for you?
*
First
Second (Must be 21 days after your 1st dose)
Third: (must be a minimum of 28 days after second dose, immunocompromised patients, 18 years of age or older)
Fourth: (must be a minimum of 3 months after 3rd dose, immunocompromised patients, 18 years of age or older: HIV, cancer, immunosuppressive medications, 65+ and long term care resident with provider consideration)
Booster 1: (minimum of 5 months from second dose, 12 years of age or older)
Booster 2: (minimum of 4 months from First Booster, 50 years of age or older)
Second Shot-Booster-1st shot was J&J (Mix, You received the J&J vaccine and has been 2 months since your dose, 18 years of age or older)
Third Shot-Booster-1st was J&J and 2nd shot was Pfizer (4 months since your 2nd dose, 18 years of age or older)
Next
Select an appointment Date
*
Select an appointment Time
*
Next
First Name
*
Middle Name
*
Last Name
*
Date of birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
26
27
28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Phone Number
*
Street Address
*
Street Address1
City
*
State
*
Zip Code
*
Email
Gender at birth
*
Please Select
Male
Female
Race
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
*
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Mother's Maiden Name
*
Required for proper vaccine documentation
Primary Care Provider Name
Emergency Contact Name
*
Relationship to Emergency Contact
*
Please Select
Brother
Sister
Sibling
Mother
Parent
Father
Guardian
Spouse
Grandparent
Child
Foster Child
Stepchild
Care Giver
Other
Next
COVID-19 Vaccine Screen Questions:
The following questions will help us determine your eligibility to be vaccinated today.
1. Do you feel sick today?
Yes
No
Don't Know
2. Have you ever received a dose of COVID-19 Vaccine?
Yes
No
Don't Know
lf yes, which vaccine product did you receive?
*
Pfizer
Moderna
Janseen
Another Product
3. Have you ever had an allergic reaction to a component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures?
Yes
No
Don't Know
4. Have you ever had a history of allergic reaction or allergies to later, medications, food or vaccines (examples: polyethylene qlycol, polysorbate. eggs. bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast or thimerosal)?
Yes
No
Don't Know
If Yes, Please list:
*
5. Have you ever had an allergic reaction to a previous dose of COVID-19 Vaccine?
Yes
No
Don't Know
6. Have you ever had an allergic reaction to another vaccine (other than COVID-19 vaccine) or an injectable medication?
Yes
No
Don't Know
7. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something other than a component of COVID-19 vaccine, polysorbate, or any vaccine or injectable medication? This would include food, pet, environmental, or oral medication allergies.
Yes
No
Don't Know
8. Have you received any vaccine in the last 14 days?
Yes
No
Don't Know
9. Have you ever had a positive test for COVID-19 or has a health care provider ever told you that you had COVID-19?
Yes
No
Don't Know
10. Have you received passive antibody therapy (monoclonal antibodies or convalescent serum) as treatment for COVID-19? [note: monoclonal antibodies does not include antibiotics that you would be prescribed and filled at a pharmacy]
Yes
No
Don't Know
11. Do you have a weakened immune system caused by something such as HIV infection or cancer or do you take immunosuppressive drugs or therapies?
Yes
No
Don't Know
12. Do you have a bleeding disorder or are you taking a blood thinner?
Yes
No
Don't Know
13. Are you pregnant or breastfeeding?
Yes
No
Don't Know
Next
Which arm would you like to get the injection on
*
Left Arm
Right Arm
Next
Consent (check each box below after reading and prior to signing the form)
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) Fact Sheet (the Pfizer Fact Sheet is available after clicking submit), a copy of which I was provided with this Consent Form. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent Form.
I understand that at this time, the COVID-19 vaccine requires 2 doses given 21-28 days apart depending on the manufacturer. If this is my second dose, I will bring my vaccine card with me to be completed.
I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur.
I understand that I will be receiving the vaccination at no cost to me.
On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the state of Tennessee Department of Health (TDOH), and their staff, agents, successors, divisions, affiliates, subsidiaries, officers, directors, contractors, and employees from any and all liabilities or claims whether known or unknown arising out of, in connection with, or in any way related to the administration of the vaccine listed in this form.
I acknowledge that: (a) I understand the purpose/benefits of TennIIS Tennessee immunization registry and (b) TDOH will include my personal immunization information and my personal immunization information will be shared with the Centers of Disease Control (CDC) or other federal agencies.
Next
The vaccine is available to anyone who is insured. Please check the following if you have insurance.
If INSURED, check this box attesting to bringing in your prescription and medical insurance cards for your vaccine appointment. By selecting this, you are also authorizing the pharmacy to bill your insurance on your behalf for the immunization – understanding you will not incur any costs.
Please Upload Insurance Card
*
Click or drag a file to this area to upload.
please select at least one of the following that you will bring with you to your appointment.
Social Security Number
State identification number and state of issuance
Driver's license number and state of issuance
Please Upload Supporting Document
*
Click or drag a file to this area to upload.
Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):
Signature
*
Clear Signature
Date Signed
*
Submit Consent Form
