Patient Forms

Thank you for selecting Mount Nittany Health to administer your COVID-19 vaccine.

Please prepare for your vaccine clinic appointment by:

• Reviewing, printing and signing your vaccination agreement form.
• You will need to bring your signed vaccination agreement form with you to your appointment.
• You will need to bring proof of Pennsylvania residency or employment, such as:
  • Pennsylvania driver’s license or Pennsylvania identification card
  • Utility bill with your name and address
  • Employer identification or badge
  • Business card

Note: There is no cost to receive the COVID-19 vaccine.

Required patient forms

• COVID-19 vaccination agreement
• Pediatric COVID-19 vaccination agreement​
  
• Pediatric COVID-19 vaccination additional dose (third dose) agreement
• Notice of COVID-19 immunization reporting requirements
• Emergency use authorization (EUA) of the Pfizer-BioNTech COVID-19 vaccine
• Emergency use authorization (EUA) of the Moderna COVID-19 vaccine

​Note: You should not get the COVID-19 vaccine if you have received any other vaccines in the last 14 days.

​Special reminders

• ​You are required to wear a mask to the vaccine site. If you will not wear a mask, then you will not be permitted to enter the site and will lose your vaccine appointment slot.
• For your safety and the safety of others, do not bring any children or other visitors with you on the day of your vaccine. One caregiver may accompany you, if needed.
• It is important that you receive both doses of the vaccine in order for it to be the most effective. 
• Please keep your vaccine appointment. If you do not arrive for your scheduled appointment time, your slot may be offered to another patient. 

COVID-19 Vaccine: Ages 18 and older

Patients of Mount Nittany Physician Group can schedule an appointment with their primary care provider for first, second, third or booster doses of the COVID-19 vaccine. Please call 814.278.4600 to schedule an appointment. 

Note: Mount Nittany Physician Group is only offering vaccine appointments to current patients. If you are not a patient of Mount Nittany Physician Group, visit vaccines.gov/search to find other COVID-19 vaccine providers in our region.

COVID-19 Vaccine: Ages 5 - 17

On January 5, the CDC expanded its recommendation of booster doses for children ages 12-17.

Parents/guardians of  Mount Nittany Physician Group patients can schedule an appointment for first or second doses for ages 5-17 or booster doses for ages 12-17 by calling 814.466.7921.

Note: Mount Nittany Physician Group Pediatrics is only offering vaccine appointments to current patients. If you or your child are not a patient of Mount Nittany Physician Group, then you may schedule a vaccine appointment with Centre Volunteers in Medicine.

Based on the CDC’s recommendation, Mount Nittany Health will not be able to give a second dose to any patient that experienced an immediate allergic reaction within four hours of receiving the first dose of the COVID-19 vaccine. Please contact your doctor immediately if you experience any moderate or severe reactions or if you have any concerns.