1-610-465-5050 or 1-610-816-5534 wecare@safecareexpress.com

 COVID-19 VACCINE APPOINTMENTS AND CONSENT FORM

 1st Dose Appointment – Pfizer Vaccine Provided by Safe Care Express

 Now Available for 16 years old and older.

 Rules to receive the 1st dose of Pfizer COVID Vaccine

Location: Safe Care Express 1802 State Hill Road, Reading PA 19610

If you HAVE an appointment at another clinic, as a courtesy, please cancel the other appointment after securing your appointment here.

1.       You MUST print the form, sign it, and bring the form with you to your appointment. You will be able to print the form once you hit “Submit”, this will allow to expedite the process efficiently. Click here to download and/or View Pfizer EUA Sheet Facts.

2.       Bring your Insurance Card. We need your insurance information.  If you are enrolled in Medicare, it is REQUIRED to provide your Medicare Card Number (MBI) found on your red-white-and-blue card.  (The vaccine is only covered by Medicare Part B, not by your Advantage or Part D plan).  If you are not enrolled in Medicare, please enter your commercial prescription coverage insurance. If you do not have insurance, please enter your Social Security Number or your driver’s license information.  This is required for us to register each dose with the State of PA Department of Health. 

3.       Your 2nd dose appointment will be announced later via email or text message. CDC’s new guidelines allow us to administer the 2nd dose up to 42 days after the 1st dose.

4.       Please arrive EXACTLY at your appointment time. Arriving earlier will cause inconvenience and chaos at the front desk.

5.       You will HAVE to sit and wait for 15 minutes after receiving the vaccine to ensure you have no initial reaction to the vaccine.

6.       Please save your appointment times and you can monitor our website for other helpful information.

7.       By submitting the form, you acknowledge that you are the identified person.

8.      Our office staff will contact you once we have received your consent form and will schedule your vaccine appointment. 

You MUST bring PHOTO ID and COPY

 

 

Step 1 of 3
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Required for proper vaccine documentation

 

 

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