WarrenVax Clinic Scheduling Form

WarrenVax COVID-19 Vaccine Scheduling Form

Clinics will be held at various locations throughout Warren County. Please choose the location at which you would like to be vaccinated in order to schedule your appointment.
The following Moderna COVID-19 (SPIKEVAX) clinics will be held in Warren County as listed below.

The CDC currently recommends a Moderna COVID-19 vaccine as an option for all adults 18 years of age and older as a primary series of 2 doses spaced 4 to 8 weeks apart. A booster dose should follow 5 months after completing the primary series. An additional booster dose for those 50 years of age and older, as well as for those with certain medical conditions, should be administered 4 months after the first booster dose.

Sheffield: May 18 & June 29, 2022

Sheffield Area Hospitality Center
511 South Main Street
Sheffield, PA 16347

Provided by Sheffield Pharmacy

Youngsville: May 19 & June 30, 2022

Youngsville Volunteer Fire Department
29 Fireman Drive
Youngsville, PA 16371

Provided by Gaughn's Drug Store

Tidioute: May 20 & July 1, 2022

Tidioute Fire Hall
224 Main Street
Tidioute, PA 16351

Provided by Gaughns Drug Store

Warren Pride Rally: June 18, 2022

Downtown Warren, PA

Provided by Pennsylvania Department of Health
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email
example@example.com
Phone Number *
Please enter a valid phone number.
Please choose the vaccine dose for your appointment *
Please Choose the location where you would like to receive your vaccine *
Sheffield Senior Center Appointments
Youngsville Fire Department Appointments
Tidioute Fire Hall Appointments
Pride Rally Appointments
Moderna COVID-19 Vaccine (SPIKEVAX) Emergency Use Authorization
Consent to Vaccinate
I have read, or have had read to me, the Emergency Use Authorization for Moderna COVID-19 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 here I agree to the above Consent to Vaccinate *

First Name Last Name
Should be Empty:

WarrenVax COVID-19 Vaccine Scheduling Form

Consent to Vaccinate