city covid

City Drugs of Curwensville

360 Thompson Street, Curwensville, PA 16833 814-236-1820
Patient Information Form for COVID-19 Immunizations

When you complete this form, Please press the Submit Button at the bottom of this page. All Fields with * are required to be completed. Uploading your Insurance Card is optional.
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date *

Month Day Year
Date
Phone Number
Please enter a valid phone number.
Email (optional)
example@example.com
In this space, Please, Upload a Copy of your Insurance Card. This is not required to complete this form but it will help us gather current information. If you are on any Medicare programs like Medicare D or others, Please copy it plus your Medicare Card.

Example: Your Geisinger, UPMC, BC, Medicare, or other, etc. Insurance card
Cancel of
Please Answer the following questions:
Are you Allergic to any Medications or Foods (yes or no): *

If yes, please list: *
Have you ever had an allergic reaction to a Vaccine:    *
Have you had another vaccination in the last 14 days:   *
Have you had the COVID-19 Infection: *
Other Contact Name if we cannot reach you.

First Name Last Name
Other Contact's Phone Number
Please enter a valid phone number.
There is NO cost to anyone for

This Vaccine.

------------------------------------------------------

We do NOT have any Vaccine NOW.

We are using this form to obtain

some information in advance

to make this process work smoothly.

We are waiting for the Vaccine

to be delivered from the State

After that, we can make appointments.

We believe it will be the Moderna Brand.

--------------------------------------------------------

Requirements:

This Vaccine requires two doses.
The 2nd dose is to be given 28 days after the 1st dose. You will be required to come in for the 2nd dose 28 days later.
We will require you to state on the day of the first dose that you have not received any other vaccination in the previous 14 days.
You must not get any other vaccinations in between these 2 doses.
You must be able to stay at our site for a minimum of 20 minutes after the injection for us to observe you.
------------------------------------------
Should be Empty:

City Drugs of Curwensville

Patient Information Form for COVID-19 Immunizations