• COVID-19 Vaccine Dose Request form

    In an effort to comply with State and CDC guidelines regarding the sequential distribution of doses of COVID-19 vaccine, please complete the following form indicating your demographic and insurance information as well as some personal background information. We will use this information to place you in the appropriate phase to receive your vaccination. We will begin vaccination with phase 1A, then move to 1B and so on. Once we are able to administer vaccines for the phase in which you qualify, we will reach out to you via the email which you provide. You will then be able to begin the process of scheduling and receiving your vaccine. We appreciate your help in ensuring that all of our doses of COVID-19 vaccine are administered in a safe, efficient and orderly fashion so that we can take the best possible care of our community. Please note that completion of this form does not constitute a reservation for a vaccine. Review of forms and distribution of vaccine following State Department of Health and CDC guidelines is at the sole discretion of Gaughn's Drug Store.
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    Pick a Date

  • Please review the following information on the phased rollout of COVID-19 vaccine in the state of Pennsylvania.  After reading this information, please choose the phase which appropritely describes you based on your age, occupation, living situation, or medical conditions.

    Phase 1A

    • Residents of Long Term Care Facilities (LTCF or Nursing Homes)
    • Healthcare Providers
      • Chiropractors
      • Dentists/Dental Hygienists
      • EMS
      • Nurses/Nursing Assistants
      • Pharmacists/Pharmacy Technicians
      • Phlebotomists  
      • Physicians 
      • Therapists 
      • Student healthcare professionals 
      • Clinical personnel in schools and correctional facilities
      • Persons not listed above but who work in healthcare facilities or are directly exposed to patients or healthcare providers
    • People aged 65 and over
    • People aged 16-64 with high-risk conditions causing increased risk for severe disease 
      • Cancer
      • Chronic kidney disease
      • COPD
      • Down Syndrome
      • Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
      • Immunocompromised state (weakened immune system) from solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines
      • Obesity/Severe Obesity (body mass index [BMI] of 30 kg/m2 or higher)
      • Pregnancy
      • Sickle cell disease
      • Smoking
      • Type 2 diabetes mellitus

     

    Phase 1B

    • People in congregate settings not otherwise specified as LTCF and persons receiving home and community-based services 
    • First responders
    • Correctional officers and other workers serving people in congregate care settings not included in Phase 1A   
    • Food and agricultural workers 
    • U.S. Postal Service workers 
    • Manufacturing workers   
    • Grocery store workers   
    • Education workers 
    • Clergy and other essential support for houses of worship 
    • Public transit workers 
    • Individuals caring for children or adults in early childhood and adult day programs 

     

    Phase 1C

    • Essential workers in these sectors: 
      • Transportation and logistics
      • Water and wastewater 
      • Food service 
      • Housing construction 
      • Finance, including bank tellers 
      • Information technology
      • Communications 
      • Energy, including nuclear reactors 
      • Legal services 
      • Government workers, including county election workers, elected officials and members of the judiciary and their staff 
      • Media 
      • Public safety 
      • Public health workers 

     

    Phase 2

    • All those ages 18 and older who have not been previously vaccinated

  • If your medical condition is NOT listed above, please add it here.

    Please note, that only the conditions listed above as check boxes are considered high-risk for the purposes of inclusion in Phase 1A at this time.

    Please list any medications that you take which you have been told weaken your immune system.    

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