COVID Vaccine Third Dose Moderna

Moderna COVID-19 Vaccine Scheduling Form

CLINICS WILL BE HELD AT THE ALLEGHENY COMMUNITY CENTER located at 42 Clark Street, Warren, PA 16365...NOT AT GAUGHN'S!
PLEASE NOTE: APPOINTMENTS FOR THESE CLINICS ARE RESERVED FOR MODERNA COVID-19 1ST AND 2ND BOOSTER DOSES ONLY. IF YOU WISH TO OBTAIN A PRIMARY SERIES OF THE MODERNA VACCINE OR NEED ADDITIONAL VACCINES, PLEASE USE THE LINK POSTED ON OUR WEBSITE AT WWW.GAUGHNS.COM TO SCHEDULE AN IN-STORE APPOINTMENT.

CDC recommends that all adults 18 years and over who have received an initial primary series of COVID-19 vaccine receive a booster dose.

CDC recommends that all adults 50 and over or who are moderately to severely immunocompromised received a 2nd booster dose.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email
example@example.com
Phone Number *
Please enter a valid phone number.
Date of Second Dose of Moderna COVID-19 Vaccine

Month Day Year
Date
Date Third Dose of Moderna COVID-19 Vaccine is DUE (5 Months after Second Dose)

Month Day Year
Date
Please choose an appointment. Please note that appointments for 1st Boosters must be 5 months from Second Full Dose; 2nd Boosters must be 4 months from 1st Booster. *
Emergency Use Authorization
Consent to Vaccinate
I have read, or have had read to me, the Emergency Use Authorization for Moderna COVID-19 Vaccine (see above) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine being administered.

I further acknowledge that all of the information provided on this form is accurate and has been provided truthfully to ensure that I am receiving my vaccine at the appropriate interval.

I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Gaughn's Drug Store, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait in the location designated by staff for approximately 15 minutes for observation by the pharmacist and or designated personnel. I have read and reviewed the Notice of Privacy Practices available at www.gaughns.com.
By typing my name here I agree to the above Consent to Vaccinate *

First Name Last Name
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Moderna COVID-19 Vaccine Scheduling Form

Consent to Vaccinate