• COVID-19 VACCINE SCHEDULING & CONSENT FORM

    This scheduling and consent form is for those ages 5 and above wanting the first or second dose of Pfizer COVID-19 vaccine, anyone 12 and above wanting Pfizer Booster and those 18 and above wanting Pfizer, Moderna or Janssen Booster. Vaccinations will be given at Strath Haven High School - Cafeteria, 205 S Providence Rd, Wallingford, PA 19086.
  • Sorry, if the person you are registering does not meet the recommendations for the Booster shot, we can not give it at this time. Thank You

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  • Insurance Information For The Person You Are Registering

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  • Pfizer Vaccine Information Sheet (VIS)

    Pharmacy Notice of Privacy Practices

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  • Please Print

    BEFORE YOU CLICK SUBMIT, PLEASE FOLLOW THE STEPS BELOW:

    1. Click Preview PDF button below.
    2. Print your form by clicking the printer icon (top right of the screen)
    3. Click "Back to Form" (top left of your screen)
    4. Hit Submit
    5. Bring your form and insurance card to the clinic.

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  • For each individual person that recieved their vaccine with us on December 20 a new consent form will need to be completed.

    Please complete the PDF below, print it, and bring it with you to the clinic on Wednesday 1/12. 

    Your appointment is at the same time as their first shot. You will also need to bring their vaccination cards and your ID.  Thank You!

     

     

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