• 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.
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  • 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: *      

  • There is NO cost to anyone for 

    This Vaccine.

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    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.

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    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.
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