COVID-19 Vaccine Request Form

COVID-19 Immunization Screening and Consent Form
• To receive the COVID-19 Vaccine you must fill out the required form below
• Please note that completing this request form does not guarantee you will receive the vaccine.
• Upon submission, if qualified, a member of the staff at Roadway will contact you to schedule an appointment.
• Please read the PA Department of Health Guidelines on Phases of Vaccine Distribution.

Influenza (Flu)

It takes about two weeks after vaccination for antibodies to develop in the body and provide protection against the flu. Flu activity most commonly peaks in the United States between December and February. CDC recommends yearly flu vaccines for everyone 6 months of age and older as the first and most important step in protecting against this serious disease.


Follow these steps to ensure a quick, easy, and pleasant experience.


Wear a short sleeve shirt so the shot is easier to give.


No appointments necessary! However, feel free to make an appointment to lessen your wait time and to let your pharmacist prepare your vaccination. It also gives us time to special order a vaccination that we don\'t have on hand.


Accept all insurances


Plan to spend about 10-15 minutes in the store after the shot, ensuring you do not have a rare, but possible allergic reaction.


Yearly vaccinations keep you and your family healthy

Why Vaccinations Are Important

In the U.S., vaccines have greatly reduced or eliminated many infectious diseases that once routinely killed or harmed many infants, children, and adults. However, the viruses and bacteria that cause vaccine-preventable disease and death still exist and can be passed on to people who are not protected by vaccines. In about the same time it takes you to pick up a prescription, you can get your next immunization.

At Risk For Serious Disease

Every year thousands of adults in the U.S. still suffer serious illness, are hospitalized, and even die due to disease for which vaccines are available. Even if you were fully vaccinated as a child, the protection from some vaccines you received can wear off. You may also be at risk for other disease due to your job, lifestyle, travel, or health conditions.

Protect Yourself And Your Loved Ones

Vaccines can lower your chance of getting certain diseases. Vaccines work with the body's natural defenses to safely develop immunity to disease and lower your chances of getting certain diseases and suffering from their complications.

Vaccinations Are Safe

Vaccines are tested and monitored. Vaccines go through years of testing before being licensed by the Food and Drug Administration (FDA). Both the CDC and FDA continue to monitor vaccines for safety after they are licensed.


If you don't see the vaccination you need listed below, please contact us for a special order.


Flu vaccination can keep you from getting sick from flu. Protecting yourself from flu also protects the people around you who are more vulnerable to serious flu illness.


PPSV23 or Pneumovax® protects against 23 types of pneumococcal bacteria. It is recommended for all adults 65 years or older and for those 2 years or older at high risk for disease. PPSV23 is also recommended for adults 19 through 64 years old who smoke cigarettes or who have asthma.


PCV13 or Prevnar 13® protects against 13 types of pneumococcal bacteria. PCV13 is recommended for all adults 65 years or older. One dose of PCV13 is also recommended for adults 19 years or older with conditions that weaken the immune system, such as HIV, organ transplantation, leukemia, lymphoma, and severe kidney disease.


People 60 years of age or older should get shingles vaccine. They should get the vaccine whether or not they recall having had chickenpox, which is caused by the same virus as shingles. Studies show that more than 99% of Americans aged 40 and older have had chickenpox, even if they don\'t remember getting the disease. There is no maximum age for getting shingles vaccine.