**NOTE: Dillon Community Pharmacy is currently only administering the Johnson & Johnson, one-dose COVID-19 Vaccine. The below form and scheduler should only be used for those who have not received another COVID-19 vaccine dose previously.**
Thank you for your submission. At this time, we are only vaccinating those for their first dose of the COVID-19 vaccine.
Please click below to download the Janssen COVID-19 Vaccine - EUA Fact Sheet for Recipients.
Janssen Vaccine EUA Form
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, an individual for whom I represent and for whom I am authorized to sign this Consent and Release.
Please click below to download the Notice of Privacy Practices.
Notice of Privacy Practices
I have received a copy of the notice of Privacy Practices. 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 would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.