COVID-19 Vaccine Request Form

COVID-19 Vaccine Request Form

Darling's Pharmacies recognizes the need for providing community members the best patient care possible and will be providing COVID-19 vaccinations in the near future. To comply with the PA Department of Health and CDC guidelines regarding the distribution of the COVID-19 vaccine, please complete the following COVID-19 vaccination request form in its entirety. This completed information will be used to place you in the appropriate distribution phase of the vaccine and ensure that vaccines are administered in an effective and efficient manner. We will contact you via phone to begin the scheduling process at your appropriate pharmacy. Please understand that the completion of this form does not guarantee a vaccine.
Name *

First Name Last Name
Birth Date *

Month Day Year
Date
Gender

Female Male
Email
example@example.com
Phone Number *
Please enter a valid phone number.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Darling's Pharmacy Location *
Are you an existing Darling's Pharmacy patient? *
Insurance
Insurance ID number
Place of Employment
Occupation

Pennsylvania COVID-19 Vaccination Phases

Please review the following information and choose the vaccination phase that appropriately describes you based upon age, occupation and medical condition.
Phase 1A
- Long-term care facility residents
- Health care personnel including, but not limited to:
  - Emergency medical service personnel
  - Nurses and Nursing assistants
  - Physicians
  - Dentists and Dental hygienists
  - Chiropractors
  - Therapists
  - Phlebotomists
  - Pharmacists and Pharmacy technicians
  - Technicians
  - Health professions students and trainees
  - Direct support professionals
  - Clinical personnel in school settings or correctional facilities
  - Contractual HCP not directly employed by the health care facility
  - Persons not directly involved in patient care but potentially exposed to infectious material that can transmit disease among or from health care personnel and patients
  - Persons ages 65 and older
    Persons ages 16-64 with specified high-risk conditions
Phase 1B
- People ages 75 and older
- People in congregate settings not otherwise specified as LTCF and persons receiving home and community-based services
- First responders
- Correctional officers and other workers serving people in congregate care settings not included in Phase 1A
- Food and agricultural workers
- U.S. Postal Service workers
- Manufacturing workers
- Grocery store workers
- Education workers
- Clergy and other essential support for houses of worship
- Public transit workers
- Individuals caring for children or adults in early childhood and adult day programs
Phase 1C
- People ages 65-74
- People aged 16-64 with high risk conditions causing increased risk for severe disease
- Essential workers in these sectors:
  - Transportation and logistics
  - Water and wastewater
  - Food service
  - Housing construction
  - Finance, including bank tellers
  - Information technology
  - Communications
  - Energy, including nuclear reactors
  - Legal services
  - Federal, state, county and local government workers, including county election workers, elected officials and members of the judiciary and their staff
  - Media
  - Public safety
  - Public health workers
Phase 2

All individuals 18 years and older not previously covered.
Based upon the above descriptions, please indicate your specific phase: *

Phase 1A Phase 1B Phase 1C Phase 2
Please list any chronic medical or high-risk conditions you have:
I hereby declare that all the given information is accurate. *

Yes No
Should be Empty:

COVID-19 Vaccine Request Form

Pennsylvania COVID-19 Vaccination Phases