Medication Allergies: allergies
There is no cost to you for the COVID-19 vaccine. By submitting the information below, you are giving consent for Gaughn's Drug Store to bill your insurance for the administration of the vaccine only. There is no out-of-pocket copay for the administration fee.
Please bring a copy of your insurace card with you to the clinic so that we can make a copy for billing purposes.
Janssen Vaccine: Lot Number: allergies Expiration:Expiration
Administration Site: Deltoid (Left/Right) blank
Date Administered: allergies Second dose due on (date): Expiration or N/A if this is second dose