COVID-19 Vaccine Request Form
Please note that completing this form does not guarantee that you will receive vaccine. Also, each person qualifies for the vaccine as an individual - not as a household. Asti's Pharmacy will contact you via email or by phone to notify you when you are eligible to book your vaccine appointment.
*Please do not submit duplicate requests for the same individual. We are aware of updated phase eligibility criteria and are prioritizing individuals accordingly.*
Vaccine Recipient Name
Vaccine Recipient Physical Address
Street Address Line 2
District of Columbia
Date of Birth
Vaccine Recipient Phone Number
Are you a current customer of Asti's Pharmacy?
No, but interested in becoming one!
Please classify your interest in the vaccine:
I am interested in the vaccine for myself
I am a business owner or manager, looking for vaccine for my employees
I represent a Residential Care Facility, looking for vaccine for my residents
*If you have multiple persons in your household looking to receive a vaccine, please submit a request for each individual*
Each person qualifies as an individual
What is the name of your facility?
What is the address of your facility?
Street Address Line 2
State / Province
Postal / Zip Code
COVID-19 Vaccine Phase Selection
Phase 1A (Frontline Healthcare Personnel or LTC Resident)
Phase 1B (Frontline non-Healthcare Critical Worker or >75 years old)
Phase 1C (Frontline non-Healthcare Essential Worker, 65-74 age, or high-risk condition)
Phase 2 (all others not in Phase 1)
I qualify for Phase 1A because:
I attest that I qualify as a paid or unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials. These health care personnel (HCP) may include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, dentists, dental hygienists, , chiropractors, therapists, phlebotomists, pharmacists, technicians, pharmacy technicians, health professions students and trainees, direct support professionals, clinical personnel in school settings or correctional facilities, contractual HCP not directly employed by the health care facility, and persons (e.g., clerical, laboratory, dietary, environmental services, laundry, security, maintenance, engineering and facilities management, mortuary, administrative, billing, clergy when working in health care settings, regulatory staff who perform on-site assessments in hospitals and facilities that meet the definition of Phase 1A long-term care facilities, long-term care ombudsmen, Older Adult Protective Services, Adult Protective Services, and Child Protective Services staff that are required to do on-site assessments in hospitals and facilities that meet the definition of Phase 1A long-term care facilities, and volunteer personnel) not directly involved in patient care but potentially exposed to infectious material that can transmit disease among or from health care personnel and patients.
Phase 1B Rationale, I attest that I am:
75 years of age or older
Law enforcement personnel
PA National Guard responders not included otherwise in Phase 1A
Older Adult Protective Services, Adult protective Services, Child Protective Services
Long-Term Care Ombudsmen
Emergency services sector personnel
Regulatory staff that are required to do on-site assessments of the 1B congregate care settings
Correctional officers and other workers serving people in congregate care settings
Food and agricultural workers
U.S. Postal Service workers
Grocery store workers
Education workers (teachers and support staff)
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 Rationale, I attest that I am:
65-74 years of age
Less than 65 years of age with a High-Risk Condition
Transportation and logistics personnel
Water and Wastewater Personnel
Food Service Personnel
Housing Construction Personnel
Finance, including bank tellers
Information technology personnel
Energy Personnel, including Nuclear Reactors
Legal Services Personnel
Federal, state, county and local government workers, including county election workers, elected officials and members of the judiciary and their staff
Public Safety Personnel
Public Health Workers
What is your High-Risk Condition that qualifies you for Phase 1C?
Please indicate the number individuals you looking to get vaccinated:
Name of your Employer/Organization:
For example: Pharmacist, Teacher, Retired, etc.
Please provide any additional information or context to support your selections above:
Please note that your submission of a response to this survey does not guarantee that you will receive a vaccine. We are following the strict CDC and PA DOH guidelines on prioritization of vaccination.
We kindly ask that you do not contact the pharmacy for an update on when you will be getting your vaccine. We assure you that you will be contacted AS SOON AS you are eligible for the vaccine - and we have vaccine in stock.
Please check your email regularly for updates from Asti's Pharmacy -
including your spam folder
! We will notify you via email when you are eligible to schedule your vaccine.
Asti's South Hills Pharmacy is committed to helping our community overcome this pandemic. Our mission is to 'Improve The Lives Of All We Touch', and we view the opportunity provide you all with access to this critical vaccine as a privilege. Thank you for trusting in us as your pharmacy provider!
Submit Request Form (required)
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