• Vaccine Scheduling Form

    Please complete the form listed below to reserve a vaccine in-store at Gaughn's Drug Store located at 348 Pennsylvania Avenue West, Warren PA 16365
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Based on your age, you may be eligible for the following vaccines:

    • Annual Influenza Vaccine
    • Annual COVID-19 Vaccine
    • Pneumonia Vaccine
    • Shingles Vaccine

     

  • Based on your age, you may be eligible for the following vaccines:

    • Annual Influenza Vaccine
    • Annual COVID-19 Vaccine
    • Pneumonia Vaccine
    • Shingles Vaccine
    • RSV Vaccine

     

  • Format: (000) 000-0000.
  • Please choose the vaccine(s) that you would like to receive (you may check more than one)*

  • At this time, we have a limited supply of Flu vaccine in stock. We are accepting walk-ins only due to limited availability from our suppliers. Please feel free to contact the store via phone to check availability.

  • At this time, we are waiting on supply of vaccine to be available from Moderna. If you are interested in receiving this vaccine, please call the store to sign up on our wait list. We will contact you directly as soon as the vaccine is available.

  • At this time, we are temporarily out of stock with COVID-19 vaccines. We expect a shipment in the coming days. Please check back to this scheduler for updated information.

  • Vaccine Appointments*
  • COVID-19 Vaccine Appointments
  • Novavax Appointments*
  • Pfizer Bivalent Booster Appointments*
  • Additional Moderna Bivalent Booster Appointments

  • Please review the Emergency Use Authorization or Vaccine Information Statement for your chosen vaccine

  • Moderna VIS
  • RSV VIS
  • Flu VIS
  • Pneumococcal Conjugate VIS
  • Shingirx VIS
  • Tetanus VIS

  • Consent to Vaccinate

  • I have read, or have had read to me, the Emergency Use Authorization or Vaccine Information Statement for the 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.

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