• COVID-19 Vaccine Registration Form

    Hereford Pharmacy 216 Mt. Carmel Rd. Parkton MD 21120

  • PFIZER AND MODERNA COVID-19 VACCINE APPOINTMENTS, INCLUDING 1ST AND 2ND BOOSTER DOSES, ARE NOW AVAILABLE THROUGH 8/19/2022

  •  -  -
    Pick a Date

  • Eligibility Questions

    Questions below will help us determine your eligibility to be vaccinated

  • The following information below is to be completed by the Healthcare Provider at Hereford Pharmacy ONLY:

  • Vaccine Lot # Exp Date Dose (mL) Route Site

    COVID-19 (PfizerBioNTech)

    		 FP7135 

    08/22/2022 

    		 0.3  IM L      R

    COVID-19 (Moderna)

    		 011B22A 11/18/2022

    0.5

    0.25

    		 IM L      R

    COVID-19 (Janssen)

    		 213D21A 04/11/2022 0.5 IM L      R

    Influenza MDV (Afluria)

    		  P100352310 05/25/2022  0.5  IM L      R

    Influenza PFS (Fluzone)

    		  UT7383LA  06/30/2022 0.5 IM L     R

    Influenza PFS (Fluzone HD)

    		 UJ772AA 06/30/2022 0.7 IM L     R

  • Vaccine Administrator:        ☐ Randy Chiat, RPh                      ☐ Keith Pfaff, Pharm.D.

                 ☐ Erica Silverstein, Pharm.D.       ☐ Megan Pfaff, RN

     

    Vaccine Administrator Signature  __________________________________

     

    Vaccine Administration Date        ________________

  • Additional Information and Resources:

    Benefits of Getting a COVID-19 Vaccine

    Getting Ready for Your COVID-19 Vaccine

    Vaccination Considerations for People with Underlying Medical Conditions

    Vaccination Considerations for People who are Pregnant or Breastfeeding

    V-Safe After Vaccination Health Checker

    Frequently Asked Questions About V-Safe

    Pfizer-BioNTech COVID-19 Vaccine General Information

    Moderna COVID-19 Vaccine General Information

    Janssen COVID-19 Vaccine (Johnson & Johnson) General Information

     

    Patient Fact Sheets:

    COVID-19 Pfizer BioNtech Vaccine EUA Fact Sheet for Recipients

    COVID-19 Moderna Vaccine EUA Fact Sheet for Recipients

    COVID-19 Janssen Vaccine (Johnson & Johnson) EUA Fact Sheet for Recipients

     

    The Day of the Appointment (PLEASE READ):

    • Arrive at the pharmacy with a photo ID and your Vaccination Record Card no earlier than 5 minutes before your scheduled appointment in order to maintain social distancing throughout the store

     

    • Please wear a loose fitting shirt that enables the healthcare provider access to the shoulder area for the administration of the vaccine

     

    • Please be prepared to wait near the vaccination location for approximately 15 minutes for observation by the healthcare provider following the administration of the vaccine

     

  • Should be Empty: