Santa Monica Medical Plaza Pharmacy Vaccination Appointment

Santa Monica Medical Plaza Pharmacy Vaccination Appointment

Please complete one appointment form PER PERSON to allows our team to prepare for your visit and helps make your appointment as quick and easy as possible.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Name (as it appears on insurance card)

FirstNameLastName
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDateOfBirth
Patient Age ( Calculated)
Gender
Patient Email Address
used for appointment Confirmation & reminder
Patient Cell Phone Number
Please enter a valid phone number. No ( ) or dashesFormat: 0000000000.
Appointment Scheduling

Please select a date and time for your vaccination appointment. If you are receiving multiple vaccines, they will be administered at the same appointment time unless you make multiple appointments
Appointment: Please pick a day and time below (to see next month's appointments, click on the down arrow next to the current month)
Click "Next" to Choose Vaccine(s)

Patient Address (as listed with insurance)

AddressOne

AddressTwo

CityStateCode

Zip
Other required information

The following 3 questions are required for all vaccines to help identify the patient among others with similar names for proper reporting of immunization records
Patiet's Race
Ethnicity
Does the Patient have Insurance
Please upload a photo of your insurance card(s) including Medi-cal, Prescription coverage and Medicare ( red, white & blue card) as applicable

PLEASE BE ADVISED. we are NOT a free clinic. if you do not have insurance or if vaccines are not covered by your plan, you will be asked to pay for the vaccine at the appointment before administration if you choose to receive the vaccination.
Cancelof
PLEASE BE ADVISED. we are NOT a free clinic. if you do not have insurance or if vaccines are not covered, you will be asked to pay for the vaccine at the appointment before administration

Rows	YES	NO
Are you immunocompromised or have underlying chronic conditions and are considered at higher risk?
Have you ever experienced a serious reaction after getting a vaccine?
Do you have allergies to any vaccine components
Are you currently pregnant or breastfeeding?
Have you experience Guillain-Barre syndrome or other Neurological conditions?

Appointment Scheduling