March 31, 2021

Covid-19 Vaccination Clinic

The date for the second dose of the COVID vaccine is April 6. Anyone who has not yet been vaccinated may sign up for their first dose.

Please note the location change for this second clinic.

In an attempt to spread the vaccines out and not have a large rush of people at one time, we are asking that you show up during the hour-long window that corresponds to your place of residence.

Windows on Park Dining Room, Tuesday, April 6

10AM – 11 AM McElwain Residents and Team Members
11 AM – 12 Noon Dyrness Residents and Team Members
12 Noon – 1PM Cottage Residents and Team Members
10AM – 1PM Supportive Living Residents and Team Members

***You will be required to be monitored for 15 minutes following vaccine administration.

How/Where to sign upIf you received the first vaccine, there is no need to sign up again.

If you have not received the first vaccine but would like to, you must contact Monica Herbein, Healthcare Coordinator, (717) 786-5341 before Friday, April 2 to make sure you are on the list. If you are questioning whether or not to receive the vaccine for medical reasons, please reach out to your primary care physician.

Required Paperwork – Assistance will be available the day of the vaccine if you have questions or difficulty completing this paperwork.

  • Pre-Vaccination Checklist for COVID-19 Vaccines – This will need to be completed and handed to the pharmacist prior to receiving the vaccine. You may complete it beforehand or fill it out the day of the clinic. We will have extra copies at the clinic if you need an extra copy. Please leave the “Form Reviewed By” line blank. It will be filled in at the time of vaccination.
  • COVID-19 (SARS-CoV-2) Immunization Consent and Record – Please complete the top section of this form sign, print your name and date the bottom section and bring it to the clinic. Team members under the age of 18, must have a parent or legal guardian sign the bottom section. Verbal authorization will be utilized for legal guardians who are unable to sign in person. Please do not fill in the back side of this page as it is for the pharmacist administering the vaccine.
  • ** COVID-19 Vaccine Insurance/Billing Form – This must be filled out and brought with you to the clinic. Please complete the top three sections and bring your insurance card with you to the clinic. A QPRC team member will be on hand to make a copy of your insurance card to include with this form.

** (Only needed for individuals receiving the first dose of the vaccine.

Please reach out to Joe Greer, Monica Herbein or Mark Smeltzer (717) 786-5295 with questions. We look forward to seeing you next Tuesday and taking another step towards a post-COVID-19 new normal.

Consent Forms

Covid-19 Consent page 1

Covid-19 Consent page 2

Pre-Vaccine Checklist