Price Rite Bozeman | Vaccine Appointment

Vaccinations are available Monday through Friday, 10 PM to 4 PM.

Please, have your insurance card with you.

If you are a Medicare patient, bring your Part B card and your prescription coverage card.

It is very important to be on-time and dress appropriately.

We are able to administer shots to individuals 12 years and older.

We are not currently not administering the Covid-19 Vaccine.

Patient Information

First Name*

Last Name*

Date of Birth (MM/DD/YYYY)*

Age*

Gender

Race/Ethnicity*

Please Choose...

Email*

Contact Phone Number*

Home Address*

Address Line 2

City*

State*

State

Zip Code*

Primary Care Physician

Physician Phone

Insurance Card

Upload an image of your insurance card or bring it to your appointment.

Vaccines To Receive At Your Appointment (Max 2)

Screening Questionaire

The following questions will help us deermine your eligibility to be vaccinated.

Are you feeling sick or experiencing a moderate to high fever?

Yes

No

Don't Know

Do you have any allergies to medications, food (i.e. eggs), latex, vaccine component (i.e. neomycin, formaldehyde, gentamicin, thimerosal, bovine protien, phenol, polymyxin, gelatin, baker's yeast etc.) If yes, please list.

Yes

No

Don't Know

Have you ever had a serious reaction to any vaccinations, including fainting and feeling dizzy?

Yes

No

Don't Know

Have you ever had a health problem with lung, heart, kidney or metabolic disease (e.g. diabetes), asthma, or a blood disorder? If yes, please list.

Yes

No

Don't Know

Have you ever had a seizure disorder for which you were on seizure medication(s), a brain disorder, Guillain-Barre Syndrome (a condition that causes paralysis) or other nervous system conditions?

Yes

No

Don't Know

For women: Are you pregnant or considering becoming pregnant in the next month?

Yes

No

Don't Know

Have you had the following vaccines?

Pneumococcal Vaccine

Have you had the Pneumococcal Vaccine?

Yes

No

Don't Know

Shingles Vaccine

Have you had the Shingles Vaccine ?

Yes

No

Don't Know

Tdap (Whooping cough) Vaccine

Have you had the Tdap (Whooping cough) Vaccine?

Yes

No

Don't Know

Schedule Vaccination

Vaccinations are available from 10 AM - 4PM, Monday - Friday. Not available on federal holidays. Please choose a time for your appointment. IF ALL TIMES SLOTS ARE NOT HIGHLIGHTED OR CLICKABLE THAT MEANS WE ARE COMPLETELY BOOKED OUT.

Fri, Sep 30

PATIENT AGREEMENT AND CERTIFICATION

I certify that I am: (a) the patient and at least 18 years of age or b) the parent or legal guardian of the patient. Further, I hereby give my consent to the healthcare provider of “Price Rite Drug”, to administer the vaccine(s) I have requested above. I understand the risks and benefits associated with the above vaccine(s) and have received, read and/or had explained to me the Vaccine Information Statements on the vaccine(s) I have elected to receive. I also acknowledge that I have had a chance to ask questions and that such questions were answered to my satisfaction. On behalf of myself, my heirs and personal representatives, I hereby release and hold harmless the applicable Provider, its 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(s) listed above. I acknowledge that I understand the purposes/benefits of my state’s immunization registry (“State Registry”) and the Provider may disclose my immunization information to the State Registry. I acknowledge that, depending upon my state’s law, I may prevent the disclosure of my immunization information by the applicable Provider to the State Registry by using the opt-out form. The Provider will, if my state permits, provide me with an Opt-Out Form. I understand that, depending on my state’s law, I may need to specifically consent, and to the extent required by my state’s law, by signing below, I hereby do consent to the Provider reporting my immunization information to the State Registry. I understand that even if I do not consent or if I withdraw my consent, my state’s laws may permit certain disclosures of my immunization information as required or permitted by law. I voluntarily authorize and direct my healthcare provider at “Price Rite Drug”, my Primary Care Physician, my insurance and/or state or federal registries, where required, for the purpose of treatment, payment or other healthcare operations. I further agree to be fully financially responsible for any cost sharing amounts, including copays, coinsurance, and deductibles, for the requested items and services as well as for any requested items and services not covered by my insurance benefits. I understand that any payment for which I am financially responsible is due at the time of service.

Signature (type your full name)*

Date

Schedule a Vaccination

Patient Information

Screening Questionaire

Have you had the following vaccines?

Schedule Vaccination

PATIENT AGREEMENT AND CERTIFICATION

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