You must book an appointment for COVID vaccines, if you have not done so, please do so before filling out this questionnaire by clicking here. If you do not book an appointment, you will not receive a vaccine.

General Info

Left/Right Deltoid is the most common choice.

Screening Questions

Some weekly injections include Remicade, Humira, Enbrell, Cimzia, Simponi, Simponi aria, Xeljanz, Orencia, Arava, Actermra, Cytoxan, Rituxan, adalimumab infliximab or etanercept.


Signature is required.

I have read, or have had read to me, the written information regarding the vaccine(s) being administered. I have had the opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) being administered and have received a copy of a current Vaccine Information Sheet. I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Lake Wylie Pharmacy, its subsidiaries, divisions, affiliates, agents, officers, directors, contractors, and employees from any and all claims arising out of, in connection with, or in any way related to the administration of the vaccine(s). I certify that I am at least 18 years old and hereby give my consent to the pharmacists of Lake Wylie Pharmacy to administer the vaccine(s). If under 18 years old signature by parent or guardian is required. I agree to wait near the vaccination location for approximately 15 minutes for observation by the pharmacist.

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