COVID-19 Vaccine Form

Read qualifications for requesting COVID-19 Vaccine from WHS.

Please read the following before requesting an appointment to receive the COVID-19 Vaccine.

Washington Health System (WHS) is in Phase 2 of Pennsylvania’s vaccine rollout. We are currently administering the Pfizer-BioNTech COVID-19 vaccine to all Pennsylvanians age 16 and older.

To request an appointment to receive the vaccine, please complete the form linked below. When filling out the form you must select the proper category – 1A, 1B, 1C, or General Public. We will notify you with your appointment date and time.

By submitting this form you agree to show up to your scheduled appointment.

Request Appointment

Please remember to be patient through this process, and please do not submit a duplicate registration or call the hospital with questions pertaining to vaccination registration as this only slows the process.

If several days have passed and you are still waiting for an e-mail confirming the receipt of your registration please try searching your junk/spam e-mail folder for an e-mail from whs. 

Cancellation/Reschedule Form
If you registered with WHS for a vaccine and have received it elsewhere, it’s very important to submit a cancellation request with us. This will allow us to focus on scheduling those that still need it. Or, if you received an appointment time, but need to reschedule, please complete the attached form as well.

Cancellation/Reschedule Form

For more information from WHS about COVID-19 response, click here.

Additional Information

COVID-19 Vaccine Form
We are in Phase 2 of Pennsylvania’s vaccine rollout. All Pennsylvanians age 16 and older are eligible to receive a COVID-19 vaccine.

Locations: NOTE you must have an appointment for all locations.

WHS Greene – Wellness Center Entrance – Lower Level 350 Bonar Ave, Waynesburg, PA 15370

Washington Crown Center – The Old Ross Location 1500 W Chestnut St, Washington, PA 15301

Peters Township Community Recreation Center – Side Entrance – Follow Signs 700 Meredith Dr, Venetia, PA 15367

  • A scheduled appointment, no walk-ins accepted
  • Your driver’s license or other government-issued photo ID
  • A mask to wear while maintaining social distancing and safety guidelines
  • Clothing that will allow unrestricted access to your shoulder and upper arm to administer your COVID-19 vaccine
  • Insurance is NOT required to get a vaccine and there will be no charges or copays to the vaccine recipient.
  • If you require reading glasses, please bring those with you so that you can complete your consent form. Or, click here to print your consent form ahead of time, fill it out at home, and bring it with you to your appointment.

We will not be able to administer your vaccine if any of these conditions apply on the day of your appointment:

  • If you have experienced any flu or COVID symptoms in the past 48 hours
  • If, within the past 14 days, you have been in close physical contact (six feet or closer for a cumulative total of 15 minutes) with someone who has confirmed COVID-19.
  • If you are isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19.
  • If you are currently waiting on the results of a COVID-19 test.

Please be sure to cancel your appointment if any of these conditions arise.

Please email your full name, date of birth and phone number to You can pick up your new vaccine card at the COVID clinic at Washington Crown Center (The Old Ross Location 1500 W Chestnut St, Washington, PA 15301) on Tuesdays between 9am-5pm. Please bring your ID with you. You must pick up the vaccine card in person at the COVID clinic. We will not mail a copy to you and we will not release it to any other individuals other than yourself.

Anyone under the age of 18 will need to have a parent or guardian with them to sign the consent. They can provide verification of demographics.



The information, including but not limited to, text, graphics, images and other material contained on this website are for informational purposes only. No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and never disregard professional medical advice or delay in seeking it because of something you have read on this website.