Vaccination Sign Up Form
‌(Phase 1A - Individual)

Must be one of the following:

·         Healthcare employee or single-person healthcare business:

·         Healthcare Employee or Single Person Healthcare Business (for full list see previous page)
‌OR ALL PERSONS:

·         Persons ages 65 and older

·         Persons ages 16-64 with high-risk conditions:

·         Cancer

·         Chronic kidney disease

·         COPD

·         Down Syndrome

·         Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies

·         Immunocompromised state (weakened immune system) from solid organ transplant or from blood or bone marrow transplant, immune deficiencies, HIV, use of corticosteroids, or use of other immune weakening medicines

·         Obesity (body mass index [BMI] of 30 kg/m2 or higher)

·         Pregnancy

·         Sickle cell disease

·         Smoking

Note that at this time only the Pfizer-BioNTech product is approved for those age 16 and 17.

*These categories are general groups. For a more granular list of eligible positions please consult the DOH vaccine plan found here:
https://www.health.pa.gov/topics/Documents/Programs/Immunizations/
‌PA%20Interim%20Vaccine%20Plan%20V.4.pdf


*Additional vaccine guidance can be found at the Department of Health's website here:
https://www.health.pa.gov/topics/disease/coronavirus/Pages/Vaccine.aspx

Vaccination Sign Up Form for 
‌Phase 1A - Individual

          **Each individual pre-registering for a vaccination requires a separate form and must have their own e-mail address.**