AuBurn Abilene Patients

Covid-19 Vaccine 4/27-4/30 - Moderna

Please review the available COVID-19 Vaccine appointment times below and sign up for the one that works best for you. **Please note that you need to be available in 4 weeks for your 2nd dose of vaccine**

After you sign up for an appointment, if, for some reason, you need to cancel or change it, you can do so by coming back to this page or by calling one of our staff members at 785-263-3770. 

Screening and Consent Form

In order to increase the efficiency of the vaccination process inside the pharmacy and to allow our pharmacy staff to vaccinate as many patients as possible, we are offering a more convenient, electronic option to complete and submit vaccination screening and consent forms. The form is HIPAA compliant so you can rest easy knowing your personal information is safe and secure.

The form can be completed via computer, tablet, or cell phone and it is sent directly to our staff once you submit it. If you choose to take advantage of this option, you do not need to bring a printed copy of the form with you or complete one upon arrival to your appointment. 

Click link below to complete electronic COVID-19 Vaccination Screening and Consent Form:

https://hipaa.jotform.com/210535150088146

 

You may also choose to print the form, complete it, and bring it to your appointment with you. If so, a PDF version of the form is attached toward the bottom of this page. 

A new screening and consent form must be completed for each dose of vaccine being administered. 

Important Information About Your Appointment

If you have insurance, please bring your insurance card with you to your appointment. If you do not have insurance or if your insurance does not cover the COVID vaccine, we will need your social security number in order to bill to a federal program set up for such purposes. 

If you have Medicare, we will need your Medicare ID Number. This number can be found on your red, white, and blue Medicare card. We cannot bill Medicare Advantage plans for the COVID vaccine; we are required to bill regular Medicare. 

If you do not have your Medicare ID Number, you can call 1-800-MEDICARE and request that they provide it to you over the phone. If possible, please ensure you have this completed prior to your appointment. 

Additional Information

At the bottom of this section you will find links to documents you may find helpful. These documents include a PDF version of the COVID-19 Vaccination Screening and Consent Form, Fact Sheet for the Moderna vaccine, and registration instructions for the V-Safe After Vaccination Health Checker. 

We appreciate your patience and understanding during this time as our staff adapts to the increased workload of managing and administering much needed COVID vaccines to our valued patients. 

If you have any questions or concerns please don't hesitate to reach out to our staff via email at [email protected] or by phone at 785-263-3770

 

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Created by:   Chelsea Doherty
 
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