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. If you do NOT have insurance we will need to obtain either your social security number or drivers license number to be in compliance with the COVID Uninsured Program.
Moderna 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