Gaughn's In-Store Multi-Vaccine Scheduling Form

Vaccine Scheduling Form

Please complete the form listed below to reserve a vaccine in-store at Gaughn's Drug Store located at 348 Pennsylvania Avenue West, Warren PA 16365
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Please choose the vaccine that you would like to receive.
Please choose the vaccine(s) that you would like to receive (you may check more than one)*

COVID-19 12 years and olderPneumoniaRSV 75 and older or 60 and older with chronic conditionsShingles 50 years and olderTetanus
At this time, we are out of stock with COVID-19 Vaccines. Please check back regularly as we expect additional supply in the coming weeks. You may still receive other vaccines at this time.

Appointments scheduled prior to October 10, 2023 have had vaccine reserved and will be honored.
At this time, we have a limited supply of Flu vaccine in stock. We are accepting walk-ins only due to limited availability from our suppliers. Please feel free to contact the store via phone to check availability.
Vaccine Appointments*
COVID-19 Vaccine Appointments
Novavax Appointments*
Pfizer Bivalent Booster Appointments*
Additional Moderna Bivalent Booster Appointments
Please review the Emergency Use Authorization or Vaccine Information Statement for your chosen vaccine
Moderna VIS
RSV VIS
Novavax EUA
Flu VIS
Pneumococcal Conjugate VIS
Shingirx VIS
Tetanus VIS
Pfizer EUA
Form Completed By:*

First NameLast Name
Consent to Vaccinate
I have read, or have had read to me, the Emergency Use Authorization or Vaccine Information Statement for the vaccine (see above) 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.

I further acknowledge that all of the information provided on this form is accurate and has been provided truthfully to ensure that I am receiving my vaccine at the appropriate interval.

I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Gaughn's Drug Store, 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 in the location designated by staff for approximately 15 minutes for observation by the pharmacist and or designated personnel. I have read and reviewed the Notice of Privacy Practices available at www.gaughns.com.
By typing my name below I agree to the Consent to Vaccinate*

First NameLast Name
Should be Empty:

Vaccine Scheduling Form

At this time, we are out of stock with COVID-19 Vaccines. Please check back regularly as we expect additional supply in the coming weeks. You may still receive other vaccines at this time.

At this time, we have a limited supply of Flu vaccine in stock. We are accepting walk-ins only due to limited availability from our suppliers. Please feel free to contact the store via phone to check availability.

Please review the Emergency Use Authorization or Vaccine Information Statement for your chosen vaccine

Consent to Vaccinate