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Covid-19 Vaccine Informed Consent


  • Answer all the questions and complete every section of the consent form.
  • Submit one form for each patient.

If any of the following questions are not clear, please ask your health care provider for assistance.

NOTE: Only register for an appointment if you can attend. At this time, we are unable to reopen cancelled appointments to other patients online. Due to limited vaccine supply, we are currently not allowing individuals to sign up for multiple appointments that are scheduled within 5 days of each other; any additional appointments attempted to be made will be blocked.


5-10 minutes.


15-20 minutes.

Documents to Upload:

Please have your insurance card and Medicare Part B red, white, blue card (if Medicare recipient) ready to upload. Uninsured individuals can still receive the vaccine at no cost.


Due to limited vaccine supply, appointments may not be available at all locations. We are updating available time slots daily. If your preferred location does not have openings at this time, please check back again via our online scheduler. We are working to roll out other vaccine appointment scheduling options, but cannot implement them until vaccine allocation increases. Please do not call Hy-Vee, as our pharmacies do not have appointments available that are not reflected online.

NOTE: Vaccines are allocated for residents in each individual state. You may be asked to show an ID to verify residency. Appointments made in states by non-residents may be cancelled.

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