12+ Booster NPHS (01-09-2022)

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Unique ID
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Has the vaccine recipient currently or have they in the past 14 days, had a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea?* This field is required.
Yes, the vaccine recipient is not eligible at this time. We are unable to schedule a vaccine for them at this time due to their potential risk for spreading COVID-19. We would be happy to schedule a vaccine at the pharmacy after 14 days - please schedule on www.skippackpharmacy.com
No
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Has the vaccine recipient tested positive for COVID-19 within the last 14 days?* This field is required.
Yes, the vaccine recipient is not eligible at this time. We are unable to schedule a vaccine for them at this time due to their potential risk for spreading COVID-19. We would be happy to schedule a vaccine at the pharmacy after 14 days - please schedule on www.skippackpharmacy.com
No
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Before you schedule your appointment* This field is required.Pfizer People receiving mRNA COVID-19 vaccines (Pfizer-BioNTech), especially males aged 5-29 years, should be aware of the rare possibility of myocarditis (inflammation of the heart muscle) or pericarditis (inflammation of the lining outside the heart) following receipt of mRNA COVID-19 vaccines and the need to seek care if symptoms of myocarditis or pericarditis (such as chest pain, shortness of breath, or palpitations) develop after vaccination.
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Select an appointment time for your COVID-19 Vaccine at North Penn High School* This field is required.****IF THE APPOINTMENT SLOTS ARE GRAYED OUT OR DATES, THESE APPOINTMENT TIMINGS ARE ALREADY FILLED. THIS APPOINTMENT IS ONLY VALID ON THE DATE OF THE CLINIC - IF YOU CANNOT MAKE YOUR SCHEDULED TIME, YOU MAY COME AT THE EARLIEST YOU CAN ON THE SAME DAY; THEREAFTER, YOU WILL NEED TO SCHEDULE A NEW APPOINTMENT ON WWW.SKIPPACKPHARMACY.COM**
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Vaccine Recipient Name* This field is required.
First Name
Middle Name
Last Name
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Vaccine Recipient's Date of Birth* This field is required.Enter without slashes or dashes (numbers only) 12+ only for this clinic.
MMDDYYYY
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Vaccine Recipient's Gender at Birth* This field is required.
Male
Female
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Vaccine Recipient Physical Address* This field is required.Please enter your full mailing address (i.e. 2020 Congo Street, Lansdale, PA 19446)
Street Address
Street Address Line 2
City
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The Bahamas
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Morocco
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Please Upload Your Driver's License or IdentificationPlease upload the front of your driver's license or ID card. If you are a parent or legal guardian accompanying a child without an ID, please upload your ID. If you have any trouble uploading, you will be asked for these at check-in.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Uploading this information in advance will expedite your registration on the actual clinic date.
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Phone Number* This field is required.Cell phone number preferred
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Email Address* This field is required.Enter an email address you check often. In case you don't receive communication from us be sure to check your spam.
I.e. jonathansmith@gmail.com
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Vaccine Recipient's Race* This field is required.
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Other Race
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Vaccine Recipient's Ethnicity* This field is required.
Hispanic or Latino
Not Hispanic or Latino
Unknown
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Emergency Contact Name + Phone Number* This field is required.
I.e. John Smith - 294-299-2945
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For vaccine recipients, you are now going to answer a series of questions.

The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means you may need to consult with your doctor or healthcare provider prior to receiving your vaccine. Healthcare professionals or staff of the Skippack Pharmacy COVID-19 Vaccine Clinic will not provide any medical guidance on if you should or should not be receiving the vaccine. This is at the discretion of the vaccine recipient and their health care provider. If you are unsure about something, we suggest you call your doctor prior to coming to the clinic.

By clicking next, you acknowledge the above.
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COVID-19 Vaccine Screening Questions* This field is required.Additional Information:https://www.cdc.gov/vaccines/covid-19/downloads/pre-vaccination-screening-form.pdf
Yes
No
1. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine, or EpiPen, or for which you had to go to the hospital? If yes, what are you allergic to?
2. Had you ever had a severe allergic reaction after receiving a COVID-19 vaccine?
3. Have you ever had a severe allergic reaction after receiving another vaccine or injectable medication?
4. Have you ever had a severe allergic reaction after receiving Polyethylene Glycol?
5. Have you ever had a severe allergic reaction related to receiving Polysorbate or products containing Polysorbate?
6. Are you currently pregnant or breastfeeding?
7. Do you have a bleeding disorder or are you taking a blood thinner?
8. Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days?
9. Are you moderately/severely immunocompromised from a medical condition/immunosuppressive therapy, including/not limited to: active treatment for solid tumor/hematologic malignancy, solid organ/stem-cell transplant, primary immunodeficiency syndrome, advanced/untreated HIV infection, or active treatment with high dose corticosteroids/other immunosuppressive/immunomodulatory biologic agents?
10. Do you have a history of Guillain-Barré syndrome (GBS)?
11. Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)?
12. Are you sick today? If you answer NO today but are sick on the day of the appointment, please consult with your physician & do not come to your scheduled appointment. You may use the same appointment anytime during the same week or if coming back for another week, you will need to schedule another appointment accordingly.
1. Have you ever had a severe allergic reaction (e.g., anaphylaxis) to something? For example, a reaction for which you were treated with epinephrine, or EpiPen, or for which you had to go to the hospital? If yes, what are you allergic to?
2. Had you ever had a severe allergic reaction after receiving a COVID-19 vaccine?
3. Have you ever had a severe allergic reaction after receiving another vaccine or injectable medication?
4. Have you ever had a severe allergic reaction after receiving Polyethylene Glycol?
5. Have you ever had a severe allergic reaction related to receiving Polysorbate or products containing Polysorbate?
6. Are you currently pregnant or breastfeeding?
7. Do you have a bleeding disorder or are you taking a blood thinner?
8. Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days?
9. Are you moderately/severely immunocompromised from a medical condition/immunosuppressive therapy, including/not limited to: active treatment for solid tumor/hematologic malignancy, solid organ/stem-cell transplant, primary immunodeficiency syndrome, advanced/untreated HIV infection, or active treatment with high dose corticosteroids/other immunosuppressive/immunomodulatory biologic agents?
10. Do you have a history of Guillain-Barré syndrome (GBS)?
11. Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)?
12. Are you sick today? If you answer NO today but are sick on the day of the appointment, please consult with your physician & do not come to your scheduled appointment. You may use the same appointment anytime during the same week or if coming back for another week, you will need to schedule another appointment accordingly.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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Consent (check each box below after reading and prior to signing the form)* This field is required.
I acknowledge & consent the above.
If I checked YES to any of the prior screening questions and its the vaccine recipient's first dose of COVID-19 vaccine, I will confirm with my doctor's office that it is okay for me to receive the vaccine prior to my appointment.
I have received/read (or had read to me) the Vaccine Information Statement(s), Vaccine Information Fact Sheet(s) and/or Patient Fact Sheet(s) regarding the vaccine(s). I understand the benefits/risks of vaccination. I voluntarily assume full responsibility for any reactions or consequences that may result. I understand I should remain in the vaccine administration area for 15 minutes, or longer if directed, after vaccination to be monitored for potential adverse reactions. In the event of side effects, I understand I should call my doctor or 911. I certify the information provided regarding eligibility for the vaccine is accurate and request the vaccine be given to me or the person previously named for whom I am authorized to make this request. If I am signing on behalf of another individual (including a minor), I attest I have the authority to do so.
I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Skippack 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 authorize Skippack Pharmacy to release information to Medicare, Medicaid or any other third party payer as needed and to request payment of authorized benefits to be made on my behalf, I certify the information provided about my Medicare, Medicaid or other coverage is correct.
Please be aware that by entering the area of the pharmacy or clinic, you consent to your voice, name, and/or likeliness being used, without compensation, in photography or film and media, and you release Skippack Pharmacy, its successors, assigns, and licensees from any liability. I will inform a member of the staff if I wish not to be included in any photos, film, or media.
If I checked YES to any of the prior screening questions and its the vaccine recipient's first dose of COVID-19 vaccine, I will confirm with my doctor's office that it is okay for me to receive the vaccine prior to my appointment.
I have received/read (or had read to me) the Vaccine Information Statement(s), Vaccine Information Fact Sheet(s) and/or Patient Fact Sheet(s) regarding the vaccine(s). I understand the benefits/risks of vaccination. I voluntarily assume full responsibility for any reactions or consequences that may result. I understand I should remain in the vaccine administration area for 15 minutes, or longer if directed, after vaccination to be monitored for potential adverse reactions. In the event of side effects, I understand I should call my doctor or 911. I certify the information provided regarding eligibility for the vaccine is accurate and request the vaccine be given to me or the person previously named for whom I am authorized to make this request. If I am signing on behalf of another individual (including a minor), I attest I have the authority to do so.
I, on behalf of myself, my heirs, executors, personal representatives, agents, successors, and assigns hereby agree to release, indemnify, and hold harmless Skippack 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 authorize Skippack Pharmacy to release information to Medicare, Medicaid or any other third party payer as needed and to request payment of authorized benefits to be made on my behalf, I certify the information provided about my Medicare, Medicaid or other coverage is correct.
Please be aware that by entering the area of the pharmacy or clinic, you consent to your voice, name, and/or likeliness being used, without compensation, in photography or film and media, and you release Skippack Pharmacy, its successors, assigns, and licensees from any liability. I will inform a member of the staff if I wish not to be included in any photos, film, or media.
I acknowledge & consent the above.
I acknowledge & consent the above.
I acknowledge & consent the above.
I acknowledge & consent the above.
I acknowledge & consent the above.
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Vaccine Recipient's Coverage Information* This field is required.I understand that I will be receiving the COVID-19 vaccine at no cost to me; however, I will provide my insurance information to the Skippack Pharmacy team for administration. If you are enrolled in Medicare, it is required to provide your Medicare Part B Card (red, white, and blue card). Your Medicare Advantage or Part D plan is not required but also may be uploaded. If you are not enrolled in Medicare and have non-Medicare insurance, please provide your commercial insurance coverage (RX & Medical).
I have Medicare
I have only non-Medicare insurance
I don't have medical insurance, Medicare, Medicaid, or any commercial or government-funded health benefit plan (by clicking this you confirm and acknowledge this). You will still receive the vaccine and there will be no cost to you.
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MEDICARE CARD: For seniors 65+ or patients with disability, please click "Upload Image or File" and upload a copy of your Medicare B card (red, white, and blue) and then click "Next." Click "Next" if you do not have a Medicare B card or have difficulty uploading it.**Having this completed will expedite registration.**
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Select files to upload
Max. file size: 10.6MB
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If on Medicare, Please enter Medicare Number on Medicare B card and click "Next". If this does not pertain to you, click "Next"I.e. 1EG4-TE5-MK72
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INSURANCE CARD: For anyone with a prescription RX/medical insurance card, please click "Upload Image or File" and upload copies of those cards herein and then click "Next." Click "Next" if you do not have an insurance card or have difficulty uploading it.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Please input the numbers/letters from your insurance card below. After filling it out, hit "Next." If you do not have active insurance, leave blank and hit "Next"If the card doesn't have a respective number or letters leave that field blank.
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NO INSURANCE: If you DO NOT have active insurance, please input the information below. Your info will help us properly bill the Health Resources & Services Administration. Either way, there'll be no cost to you. If this does not apply to you, click "Next"
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Which arm would the vaccine recipient like to receive the vaccine?Please inform the staff member or volunteer at check-in & the vaccinator which option you select.
Left
Right
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Signature of Parent/Guardian* This field is required.
Clear
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Date Signed
Date
Month
Day
Year
Should be Empty: