COVID-19 Vaccination Request Form
Please note that completing this form does not guarantee that you will receive the vaccine. The team from Rann Pharmacy will contact you via email or phone to notify you when you are eligible to book your vaccine appointment as the vaccine becomes available. If you are filling this form out for additional family members over 18 years of age, please fill out ONE FORM PER PERSON. The vaccines will be provided at no cost to the patient.
Full Name (First Name & Last Name & Middle Initial)
Date of Birth
Phone Number (Cell Phone Preferred)
Are you a current patient of Rann Pharmacy?
Interested in becoming one
What is your vaccine interest?
I am an individual, looking to obtain the vaccine for myself and/or my family (over the age of 18)
I am an owner/manager/admin, looking to obtain the vaccine for my staff/school/workplace/institution (if so, please include name of location/site in 4th option-OTHER)
I represent a Long-Term Care Facility or Nursing Home looking to obtain vaccine for my residents/staff (if so, please include facility in 4th option-OTHER)
Because the supply of COVID-19 vaccine in the United States is expected to be limited at first, the CDC is providing recommendations to federal, state, and local governments about who should be vaccinated first. CDC’s recommendations are based on recommendations from the Advisory Committee on Immunization Practices (ACIP), an independent panel of medical and public health experts. The recommendations were made with these goals in mind: *Decrease death and serious disease as much as possible. *Preserve functioning of society. *Reduce the extra burden COVID-19 is having on people already facing disparities. * *
Please choose the Vaccination Phase according to the PA Department of Health that best describes your situation or condition. **This is an interim vaccine plan from the department. Many components of the COVID-19 vaccine plan remain fluid and continue to be modified and adapted as more announcements and decisions are made at the federal level. The department is continuing to receive feedback and will be modifying this plan and posting public updates to this in the coming weeks.**
Phase 1-A (e.g. Healthcare worker, Long-term care resident, age 65+, age 16-64 with high-risk condition)
Phase 1-B (e.g. Community-based worker, education worker, first responder)
Phase 1-C (e.g. Essential worker in various sectors)
Phase 2: (e.g. Anyone at least 16 years old without a contraindication to the vaccine)
It is the perfect time to be up-to-date with your vaccines. Rann Pharmacy has a variety of vaccine offerings of which most are covered by your prescription plans. If interested in learning more about or receiving any of the below, please select (otherwise leave blank). CDC Vaccine Schedule:
Boostrix (Diphtheria, Tetanus, and Pertussis)
Engerix-B (Hepatitis B)
Havrix (Hepatitis A)
Pneumovax-23 / Prevnar-13 (Pneumococcal Vaccine)
Shingrix (Zoster Vaccine)
Fluad 65+ / Flucelvax (Influenza)
DISCLAIMER: please note that your submission of a response to this survey does not guarantee that you will receive a vaccine. We are following the strict CDC and PA DOH guidelines on prioritization of vaccination. We kindly ask that you do not contact the pharmacy for an update on when you will be getting your vaccine. We assure you that you will be contacted AS SOON AS you are eligible for the vaccine - and we have vaccine in stock. THANK YOU for your patience and understanding! *
DATA: Data from this form will not be shared however, I acknowledge & give consent to Rann Pharmacy to communicate with me via phone or email. *
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