1200 First Ave New York, NY 10065
212-734-6998
goldbergersrx@gmail.com

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Walk-In Vaccination Services - No Appointment Needed! Stop by anytime between 11 AM and 6 PM on weekdays for quick and convenient vaccinations. Walk-ins are always welcome!

Walk-In Vaccination Services - No Appointment Needed! Stop by anytime between 11 AM and 6 PM on weekdays for quick and convenient vaccinations. Walk-ins are always welcome!

Vaccine Consent Form

In order to receive the vaccine, you must be in the most appropriate phase of the vaccine rollout. Visit this link (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html) for more information at the federal level. States may have a different approach.

Vaccine Recipient Name

Vaccine Recipient Physical Address*

Vaccine Screen Questions

Yes

No

Don't know

1. Are you feeling sick today?

2. Do you have any health conditions such as: heart disease, diabetes, or asthma?

3. Do you have allergies to latex, medications, food or vaccines? (Examples: eggs, bovine protein, gelatin, gentamicin, polymyxin, neomycin, phenol, yeast, or thimerosal)?

4. Have you ever had a reaction after receiving an immunization including fainting or feeling dizzy?

5. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barré Syndrome (a condition that causes paralysis) or other nervous system problem?

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

Flu Nasal Spray (FluMist® Quadrivalent) Questions

Yes

No

Don't know

1. Are you receiving aspirin therapy or aspirin-containing therapy? (18 years of age and younger only)

2. Do you have a nasal condition serious enough to make breathing difficult, such as a very stuffy nose? (For FluMist® only)

Please Upload your ID Picture (Optional)

Please Upload the front side picture of your Insurance Card (Optional)

Please Upload the back side picture of your Insurance Card (Optional)

Signature of Person to Receive Vaccine & EUA /VIS (or Signature of Parent/Guardian if Patient is < 18 years old):

Frequently Asked Questions

Your Questions Answered for A Better Pharmacy Experience

How do I transfer my prescriptions to Goldberger's Pharmacy?

Do you offer same-day or next-day delivery?

Which insurance plans do you accept?

Can I refill prescriptions online?

Do you offer compounding services?

How do I transfer my prescriptions to Goldberger's Pharmacy?

To transfer your prescriptions, simply fill out our online transfer form or call us with your previous pharmacy’s details. We’ll handle the rest—contacting your former pharmacy and setting up your medications for pickup or delivery.

We're Here to Help

Reach Out Anytime - We're Just a Message Away

Phone

212-734-6998

Phone

goldbergersrx@gmail.com