Instructions
Welcome to the Excela Health vaccination site. This site is used to schedule your appointment for COVID-19 vaccination at the Excela Health Vaccine Clinic located at 8885 Norwin Avenue, North Huntingdon, PA 15642 (formerly Galaxy Fitness).
Excela offers both Pfizer and Moderna COVID-19 Vaccines. You may mix vaccines manufacturers if necessary.
Pfizer:
Initial two-dose series of vaccination is available for anyone five years of age or older, two doses at least three weeks apart.
Third dose is available to immunocompromised individuals five years of age or older at least 28 days after second dose. Please contact your physician with any questions.
A booster dose is recommended for anyone 12 years of age or older, at least five months after completion of your initial series (second dose).
Moderna:
Initial two-dose series of vaccination is available for anyone 18 years of age or older, two doses at least four weeks apart.
Third dose is available to Immunocompromised individuals 18 years of age or older. Please contact your physician with any questions.
A booster dose is recommended for anyone 18 years of age or older, at least five months after completion of your initial series (second dose).
Start
Biographical Information
This form is being completed for
Myself (I am the Patient)
Someone Else (I am entering someone else as the Patient)
Proxy Information
Person Entering First Name:
Proxy First Name
Person Entering Last Name:
Proxy Last Name
Patient First Name:
Patient First Name (As it appears on State Issued ID)
Patient Middle Name/Middle Inital (optional):
Patient Middle Name (If it appears on your State Issued ID (Middle Inital))
Patient Last Name:
Patient Last Name (As it appears on State Issued ID)
You must be 18 years or older to receive the Moderna vaccine.
You must be 5 years or older to receive the Pfizer vaccine.
Patient Date of Birth:
Patient Date of Birth is in either the wrong format or Patient Date of Birth is less than 18 years old.
Patient Gender
Male
Female
Prefer Not to Say
Please select the option that is most appropriate for the Patient.
Patient is a long-term care facility resident
Patient is a healthcare worker
Patient resides in a group care setting and receiving community services to support their care
Patient has a high-risk condition
Patient receiving in home community based services visiting nurses, therapies, personal care assistance
Patient is a first responder
Patient is a correctional officer or other worker serving people in congregate care settings
Patient is a food or agricultural worker
Patient is a U.S. Postal Service worker
Patient is a manufacturing worker
Patient is a grocery store worker
Patient is a education worker
Patient is a clergy and other essential support for houses of worship
Patient is a public transit worker
Patient is caring for children or adults in early childhood or adult day programs
Patient is an essential worker
Patient is not listed above
Patient is a Student
Please select the Patient's occupation
Emergency medical service personnel
Nurse
Nursing assistant
Physician
Dentist
Dental hygienist
Chiropractor
Therapist
Phlebotomist
Pharmacist
Technician
Pharmacy technician
Health professions student or trainee
Direct support professional
Clinical personnel in school settings or correctional facilities
Contractual HCP not directly employed by the health care facility
Please select the High Risk Condition that applies to the Patient. (Only one is required.)
Cancer
Chronic Kidney Disease
COPD
Down Syndrome
Heart Condition such as heart failure, coronary artery disease, or cardiomyopathies
Immunocompromised state
Obesity (BMI of 30kg/m2 or higher)
Pregnancy
Sickle Cell Disease
Smoking
Type 2 Diabetes mellitus
Patient's Occupation
Transportation and logistics
Water and wastewater
Housing construction
Finance, including bank tellers
Information technology
Communications
Energy, including nuclear reactors
Federal, state, county and local government workers, including county election workers, elected officials and members of the judiciary and their staff
Media
Public safety
Public health workers
Additional Questions
Is the Patient a healthcare worker?
Yes
No
Is the Patient an Excela Health Employee?
Yes
No
What is the Patients race?
Black, African American
Asian
White
American Indian, Alaska Native
Native Hawaiian, Other Pacific Islander
Decline to answer
What is the Patients ethnicity?
Hispanic or Latino
Non-Hispanic or Non-Latino
Decline to answer
Warning! You are missing required fields marked in red. Please check you entries and try again.
Next
Vaccination Information
Please choose your vaccine (select one)
The Patient only wants the Pfizer-BioNTech COVID-19 Vaccine - 2 Doses - 21 Days Apart - 12 Years old or Older
The Patient only wants the Moderna COVID-19 Vaccine - 2 Doses - 28 Days Apart - 18 Years old or Older
The Patient only wants the Johnson and Johnson Vaccine - 1 Dose
*
The Patient will take any vaccine available
Is the patient currently on another vaccine registry? (optional)
Yes
No
Warning! You are missing required fields marked in red. Please check you entries and try again.
Next
Contact Information
Please Enter Home Address:
Please Enter The Patients Home Address
Please Enter The Patients Home Address (Line 2 - optional):
Zip Code:
Please Enter the Patients Zip:
City:
Please Enter the Patients City:
State:
Please Enter the Patients State:
Contact Phone Number:
(Number you will be reachable)
Please Enter the Patients Phone Number
A valid email address is required as all communication from Excela Health will come via email!
Email Address:
An Email Address is Required.
Confirm Email Address:
Please Confirm Your Email Address
Warning! You are missing required fields marked in red. Please check you entries and try again.
Next
Scheduling
Schedule Information
Please select a vaccine
Please select a location
Please select a preferred time:
This vaccine requires 2 doses. Your second dose will be at:
Acknowledgements
I am committing to be present at both my first and second dose appointment.
I cannot rescheuled my scheduled second dose once I receive my first dose.
The information you entered is True and Accurate.
I Acknowledge
Your vaccine dose will be at:
Acknowledgements
I am committing to be present at this appointment.
The information I entered is True and Accurate.
I Acknowledge
Schedule My Vaccine
Start Over
Confirmation
Confirmation
Thank you for using eVaccinate to Self Schedule.
You have been scheduled for your vaccination(s). The confirmation e mails may take up to 15 minutes to be received. If you are unable to locate the confirmation e-mail, please look in your "junk" or "spam" folders. The confirmation e-mail will include the following:
Your Appointment Date
Your Appointment Time
Your Appointment Location
Instructions on how to cancel your appointment if you are unable to make the appointment.
Please note if the vaccine you selected requires multiple doses you will receive a confirmation email for each appointment.
Please bring the following with you to expedite your appointment
Photo Identification
Insurance Card
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