1336 Powell St, Norristown, PA 19401
PA has not sent us any first doses of vaccine since 1/28. We cannot schedule any new appointments until we get more vaccine in stock. We will try our best to reach out when they send more to us. Additionally, we currently have over 5000 submissions to this form. We will try our best to get back to you, but it may be awhile before you receive a scheduling link from us. Please do not email or call us to ask where your place in line is. If the form is submitted, you may not receive a confirmation, but you will be entered into our waitlist.
COVID VACCINE FORM
This form is HIPAA secure. Any information in this form will only be seen and processed by LaCon's Pharmacy. Currently we are only able to offer the vaccine to HealthCare Workers or long term care facility residents!
Please fill out this form, and then we will reach out to you to schedule a vaccination appointment.
What phase do you belong to?
Please list the name of your Employer or LTC Facility. If you are not working or retired please enter that. Thank you.:
Are you a current customer of LaCon's Pharmacy
No but I'm interested in becoming one
Screening Questionnaire for Adult Immunization and Consent Form
For Patients: The following questions will help us determine if you are eligible to receive the COVID vaccine. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it
PLEASE READ BEFORE CONTINUING!
The COVID-19 vaccine should NOT be administered to anyone who is presently ill or who has an active case of COVID-19. Those with a history of severe allergic reaction to any of the components of the Moderna COVID-19 vaccine should not be vaccinated at this time.
Please enter a valid phone number.
Type Of Insurance
Social Security Number (not required)
Secured by HIPAA standards
Allergies (if none, write "none")
Street Address Line 2
State / Province
Postal / Zip Code
Prefer Not To Say
Date Of Birth
Primary Care Physician
Have you ever had a serious reaction after receiving a vaccination?
Has the person to be vaccinated ever had Guillain-Barré syndrome?
Have you received COVID-19 monoclonal antibodies or convalescent plasma in the last 90 days?
I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information. This form is available for review by requesting a copy from our pharmacy staff.
When you click submit, your entry is entered into our system. We will reach out for an appointment as soon as we can via e-mail. You will not receive a confirmation of submission to this form.
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