PHS COVID-19 Vaccination Forms
Individuals scheduled to receive a COVID-19 vaccination should fill out the Consent Form for the vaccine to be given and bring the completed form to your scheduled appointment.
Please note, if you currently have COVID-19 or have received antibody therapy for COVID-19 within the last 90 days you will need to reschedule.
VSAFE Information Sheet – English
Hoja de información de VSAFE – Español
Moderna Consent Form – English
Moderna Fact Sheet -English
Formulario de consentimiento de Moderna – Español
Hoja informativa de Moderna – Español
Questions about the COVID-19 vaccines?
Visit the CDC website HERE to learn more.
Pfizer (12 years and older):
Pfizer Fact Sheet – English
Pfizer Consent Form – English
Hoja informativa de Pfizer – Español
Formulario de consentimiento de Pfizer – Español
Pfizer (5-11 years old):
Pfizer 5-11 years – Screening/Consent Form
Pfizer 5-11 years – Fact Sheet
Pfizer 5-11 años – Hoja de consentimiento
Pfizer 5-11 años – Hoja informativa
Looking to get a Covid-19 Vaccine?
PHS offers the Moderna and Pfizer vaccine.
Individuals ages 5-18 must be accompained by a parent/guardian.
If you are homebound or have a disability
If you are homebound or have a disability that makes it difficult to get a Covid-19 vaccination, please contact our office. A nurse will return your call and make sure you have access to a Covid vaccination.
Call our office at 402-826-3880.
If you are pregnant and have questions about Covid-19 vaccine
If you would like to speak to someone about Covid-19 vaccination during pregnancy, you can contact MotherToBaby whose experts are available to answer questions in English or Spanish by phone or chat. The free and confidential service is available Monday-Friday, 8am-5pm.