Booster PFZ, MOD Passavant Center 10.27.21

  • Thank you for your interest in our COVID-19 Vaccination Clinic.

    This clinic will provide Pfizer COVID-19 Vaccine for patients 12 and older or Moderna COVID-19 for those 18 and older.  

    Pfizer COVID-19 Vaccine is for ages 12 and older.  For any person under 18, a parent or guardian must complete the consent form and all minors must be accompanied by a parent or guardian at time of vaccination. 

    This clinic is for first, second or booster doses of Pfizer or Moderna COVID-19 Vaccine. 

    Booster doses will be administered as followed:

    The CDC issued the following guidance for booster doses to individuals who received their Moderna or Pfizer primary series at least six months ago:  

    65 years and older
    Age 18+ who live in long-term care settings
    Age 18+ who have underlying medical conditions
    Age 18+ who work or live in high-risk settings
     

    For individuals who received a Janssen vaccine (J&J) as their primary dose at least two months ago, the CDC guidance recommends a booster dose to all individuals who are 18 or older. 

    According to the CDC, booster is now recommended for all three available COVID-19 vaccines in the United States.

    Individuals have ability to decide which vaccine they receive as a booster dose. Some individuals may prefer to receive booster of the same vaccine type they received as primary series while others may prefer to get a different booster. CDC is now allowing such mix and match of vaccines for booster shoots.  

    When administering booster doses, providers should note that the Pfizer and Janssen vaccines are the same product and dose as the primary series, but the Moderna vaccine is a half dose of the same product when compared to the primary series. 

     

    Please come at your scheduled appointment time.

  • COVID-19 Immunization Consent Form and Appointment Scheduler

    Please complete prior to arriving for your appointment.

  • *IMPORTANT*

    This scheduling tool is intended only for those individuals that qualify for the current COVID Vaccination Phase of distribution. Please come at your scheduled appointment time.

  • Pfizer/Moderna COVID-19 Vaccination Clinic at Passavant Center at Thiel College

    38 Packard Avenue, Greenville, PA 16125
  •  - -

  •
  • Format: (000) 000-0000.
  •  - -

  • Patient Consent For COVID-19 Vaccination

  •  - -

  • Insurance Information

    There is no charge for the vaccine to you. By completing this form, you are providing consent for Walberg Family Pharmacies to bill your insurance for the administration of the COVID vaccine. Please bring all insurance cards at time of appointment.
  • Image field 134

  • Consent Questions to Receive COVID-19 Vaccine

    Please complete the following questions.

  • Consent to Vaccination

    I have read, or have had read to me, the written information regarding the COVID-19 vaccine 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 and have received a copy of a current COVID Vaccine Fact Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Walberg Family Pharmacies, 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. Parent or guardian must be present at time of vaccination. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist. I have read and reviewed the Notice of Privacy Practices available at www.walbergfamilypharmacies.com.

  • Pharmacy Use Only

    Do no complete the below questions

  • Right Deltoid / Left Deltoid

    Circle

  • Pfizer COVID-19 Vaccine LOT/EXP: FF2590 03/31/2022

    Moderna COVID-19 Vaccine LOT/EXP: 006D21A 11/21/2021

    Date Administered: Oct 27, 2021

     

  • Signature of Pharmacist Administering 

  • Should be Empty: