Riley's PharmacyGlendale, California Call 818-244-1195

Flu shot signup, two minutes.

Tell us who is coming so the pharmacist can prepare. First, complete and submit your information below. Your receipt will then offer an optional appointment time or consent for a walk-in visit. For help, call 818-244-1195. We are currently accepting children 12 years and older.

1. Who is this flu shot for?

First name

Last name

Date of birth

Mobile phone

Street address

Apartment / unit (optional)

City

State / territory

ZIP code

Sex

Male Female

2. Have you had a flu shot this season already?

No, this is my first this season Yes, I have

3. Do you have insurance you want us to bill?

Yes, here are my details No, cash price please

Medicare number (optional)

As shown on your Medicare card. Leave blank if it does not apply, or bring your card to your visit.

Member ID

Rx BIN

Rx PCN

Rx Group

These are printed on your card, usually along the bottom. Or skip this and we will copy your card at the counter.

4. Do you have any allergies?

Yes No

Please list your allergies

Type your allergies here so the pharmacist can review them.

Quick check that you are a person, then hit the button.

Vaccine coverage varies by plan and patient, so ask us for details. We also have a cash price.