COVID-19 VACCINES ARE NOW AVAILABLE!

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COVID-19 Vaccination

We are no longer taking new COVID-19 Vaccine Form applications at our 164 5th Ave location. Please check back at a later date.

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Personal Information

Name *

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Day

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Front of Insurance Card

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Back of Insurance Card

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personal Address *

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Current Pharmacy Information

Pharmacy Name *

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Pharmacy Address *

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Location transferring to *

Please list all of the medications you would like to transfer or list Rx number. *

If this is being filled out by a caregiver, case manager, or care coordinator kindly include your full contact information (Name, Contact info, Name of facility)

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Locations

500 4th Ave,
Brooklyn, NY 11215
718-567-5444
–
164 5th Ave
Brooklyn, NY 11217
718-393-5555
–
info@parkchemistsrx.com

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