(512) 296-2633
info@texanrx.com

(512) 296-2633
info@texanpharmacy.com

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Pharmacy
About Us
- Career With Us
For Patients
For Professionals
- Facilities
- Physicians
Contact Us
- Resources
- News & Blogs

Pharmacy
About Us
- Career With Us
For Patients
For Professionals
- Facilities
- Physicians
Contact Us
- Resources
- News & Blogs

Protect What Matters - Get Vaccinated Today

Texan Pharmacy offers convenient, walk-in immunizations for all ages. From flu shots to travel vaccines, our trained pharmacists are here to keep you and your family protected — safely, quickly, and with care.

Book Vaccination

Patient, Vaccine & Schedule Details

First Name

Last Name

Date of Birth

Phone #

Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Gender

Ethnicity/Race

Choice of Vaccine

Schedule Date

Schedule Time

Hours

Minutes

AM/PM

Insurance Details & Authorization

Insurance Provider Name

Card ID

BIN

PCN

Group ID

Medicare Card (MBI, Red, Blue & White Card)

Uninsured (Last four of SSN)

Remarks (Note for Pharmacy)

Medical Checklist

1. Are you pregnant?YesNo

2. Are you currently breastfeeding?YesNo

3. Have you had a severe allergic reaction (e.g., anaphylaxis, trouble breathing) to any vaccine or injectable therapy, or a history of anaphylaxis due to any cause?YesNo

4. Have you had a severe allergic reaction (e.g., anaphylaxis, trouble breathing) to any component of a COVID-19 vaccine, including lipid nanoparticles or polyethylene glycol (PEG)?YesNo

5. Have you received any other vaccine within the past 14 days or are scheduled to receive any vaccine in the next 14 days?YesNo

6. Have you received convalescent plasma or monoclonal/polyclonal antibody infusions for COVID-19 within the past 90 days?YesNo

7. Are you under age 16?YesNo

8. Are you currently sick? For example, are you currently experiencing fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, etc.?YesNo

9. Do you have a bleeding disorder or are you taking a blood thinner?YesNo

10. Have you tested positive for COVID-19 in the last 10 days?YesNo

11. Are you currently in quarantine for COVID-19 exposure?YesNo

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

13. 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?YesNo

14. Do you have a condition that may weaken your immune system (e.g., cancer, leukemia, lymphoma, HIV/AIDS or transplant)?YesNo

15. Have you received any vaccinations or skin tests in the past four weeks?YesNo

16. Are you currently on home infusions, weekly injections such as Humira™ (adalimumab), Remicade™ (infliximab) or Enbrel™ (etanercept), high-dose methotrexate, azathioprine or 6-mercaptopurine, antivirals, anticancer drugs or radiation treatments?YesNo

17. Are you currently taking high-dose steroid therapy (prednisone > 20 mg/day or equivalent) for longer than two weeks?YesNo

18. Have you received a transfusion of blood, blood products or been given a medication called immune (gamma) globulin in the past year?YesNo

19. Are you currently taking any antibiotics, antiviral or antimalarial medications? (Typhoid only)YesNo

20. Do you have a history of thrombocytopenia or thrombocytopenic purpura? (MMR only)YesNo

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

22. Do you have a nasal condition serious enough to make breathing difficult (e.g., very stuffy nose)?YesNo

23. Have you ever received a dose of COVID-19 vaccine?YesNo

Select Product (If Yes)

Date Of Vaccine

Signature (Initials)

Date

Vaccination Consent *

I have reviewed my answers to the questions above with the vaccinator. If I experience any adverse reactions after leaving, I will notify my primary care provider. I have viewed the Emergency Use Authorization Fact Sheet provided to me today. I understand the benefits and risks of the vaccine. The vaccine checked above should be given to the person named above for whom I am authorized to make this request. I understand that I can review a Notice of Privacy Practice at the time of vaccination.

Patients Love Texan

We could tell you why Texan Pharmacy is the best choice for your care — but we’d rather let our patients do the talking. From fast, friendly service to going the extra mile when it matters most, their words say it all. Real experiences. Real voices. Real care.

Your health isn’t just a number

IT IS OUR PRIORITY AT TEXAN

At Texan Pharmacy, we deliver care that feels personal, because it is. Refill your prescriptions, speak with a pharmacist who knows your name, and experience the difference of a pharmacy that treats you like family. Let’s take care of your health, together.

Transfer Prescription

Prescription # *

Previous Pharmacy Name

Pharmacist Name

Pharmacist Phone

Patient Name

Patient Phone

Patient Cell (Mobile)

Patient Email Address

CheckboxPickupDelivery

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HIPAA Consent *

Yes, I agree with the privacy policy and terms and conditions.

Any Important Instructions

talk to a pharmacist

Feel free to call (512) 296-2633 to speak to a pharmacist today.

Contact Us

Let’s get in touch

We love answering questions.

First Name

Last Name

Email Address *

Phone *

Text

Consent *

Yes, I agree with the privacy policy and terms and conditions.

As a part of a health care team, We provide services like compounding of the medications (non- sterile) immunization, Medication Therapy Management; Prescription medications.

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(512) 296-2633
info@texanrx.com