IMMUNIZATION FORM (Flu, Pneumonia, RSV, Shingles, Tdap, M.M.R., Hep-B, Meningitis & Covid-19 vaccines)

Request edit access

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

MEDEX PHARMACY
96-02 Jamaica Ave, Woodhaven, NY 11421
(718) 805-7000
Please Register and Call to schedule your appointment at Medex Pharmacy. WALK-IN ARE WELLCOME !!!
Please bring to your appointment: your picture I.D.(driver license, passport), Insurance Card, Print and Sign CONSENT FORM:

https://drive.google.com/file/d/1VAbcP0IcBThThLvnQEND8TXE0waDRtsr/view?usp=drive_link

CDC maintains a current list of Vaccine Information Statements (VIS) for each vaccine. You may find this VIS for each vaccine here:
https://www.cdc.gov/vaccines/hcp/vis/current-vis.html

To find your nearest COVID-19 mass vaccination location in NYC visit : https://vaccinefinder.nyc.gov/

Last Name *

First Name *

Date of Birth *

Age *

Phone Number (xxx) xxx-xxx *

Address: Street, State, City, Zip *

Read this Fact Sheets for information about the RSV, COVID-19 and all other Vaccines.

CDC maintains a current list of Vaccine Information Statements for each vaccine. You may find VIS for each vaccine here:
https://www.cdc.gov/vaccines/hcp/vis/current-vis.html

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms