• 1st Dose PFIZER COVID-19 Vaccine Registration Form

    You must be 16+ to receive the Pfizer vaccine!
  •  -  -
    Pick a Date
  • Screening Questionnaire

    Please complete the following questions.
  • If you have received a vaccine, such as the flu, shingles, and pneumonia vaccine, you must wait at least 2 weeks before receiving the COVID-19 vaccine. 

    If you recieved antibody therapy, you must wait 90 days before receiving the COVID-19 vaccine. 

  • Consent to Vaccination

    I have read, or have had read to me, the written information regarding the COVID-19 vaccine being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine being administered and have received a copy of a current COVID Vaccine Fact Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Drugco Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist. I have read and reviewed the Notice of Privacy Practices available at www.drugcopharmacy.com.
  • APPOINTMENT OPTIONS ARE SHOWN BELOW:

    Please only make an appointment for one day and time!  

    • Thursday 4/22 - PFIZER at Kirkwood Adams
    • Friday 4/23 - PFIZER at HMS at Rural Health Group
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