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Cook's Pharmacy Immunization Questionnaire

Please fill out the following form to help us understand your vaccine eligibility

Please fill out the following form to help us understand your physical condition.

Have you read the phase criteria as established by the Department of Health listed to the right?


Do you currently qualify to receive the vaccine?


*If you do not fall into this group of criteria (Phase 1A) Please to check back to our website or facebook page regularly.

Pennsylvania Is Currently In Phase 1A You MUST Be In This Group To Be Eligible For The Current Vaccination Schedule.

• 65 Years of Age or Older

• Long-term care facility residents

Health care personnel including, but not limited to:

• Emergency medical service personnel

• Nurses

• Nursing assistants

• Physicians

• Dentists

• Dental hygienists

• Chiropractors

• Therapists

• Phlebotomists

• Pharmacists

• Technicians

• Pharmacy technicians

• Health professions students and trainees

• Direct support professionals

• Clinical personnel in school settings or correctional facilities

• Contractual HCP not directly employed by the health care facility

• Persons not directly involved in patient care but potentially exposed to infectious material that can transmit disease among or from health care personnel and patients

Phase 1A

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