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.
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
Darling's Pharmacy Location
Darling's Pharmacy Sugar Grove
Darling's Pharmacy Oil City
Are you an existing Darling's Pharmacy patient?
Would like to transfer my prescriptions!
Insurance ID number
Place of Employment
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.
Long-term care facility residents
Health care personnel including, but not limited to:
Emergency medical service personnel
Pharmacists and Pharmacy 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
People ages 75 and older
People in congregate settings not otherwise specified as LTCF and persons receiving home and community-based services
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
Grocery store 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
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
Finance, including bank tellers
Energy, including nuclear reactors
Federal, state, county and local government workers, including county election workers, elected officials and members of the judiciary and their staff
Public health workers
All individuals 18 years and older not previously covered.
Based upon the above descriptions, please indicate your specific phase:
Please list any chronic medical or high-risk conditions you have:
I hereby declare that all the given information is accurate.
Should be Empty: