COVID-19 Vaccine In Store
This form is ONLY for people who received their first dose
COVID-19 vaccine in Fairmount Pharmacy
from April 8 thru April 16, 2021.
You must bring your CDC vaccination record card with you.
Completing this form will allow you to schedule a SECOND DOSE appointment to receive the COVID-19 vaccine at
1900 Green Street
Philadelphia, PA, 19130
PLEASE BRING YOUR INSURANCE CARD AND ID.
PLEASE WEAR SHORT SLEEVES FOR EASE OF ACCESS TO INJECTION SITE.
You must bring your CDC Vaccination Record Card with you.
We look forward to seeing you!