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3-4 Year Old - PFIZER COVID-19 Vaccine
3-4 Year Old - PFIZER COVID-19 Vaccine
The vaccines will be provided inside Skippack Pharmacy (4118 W Skippack Pike, Schwenksville, PA 19473), located across Wawa Skippack.  Please fill this form in its entirety prior to arrival and bring your RX insurance card and a form of ID prior to arriving at the pharmacy.  Uploading your ID/insurance card in advance will help expedite your visit.  This form is ONLY for 3-4 year olds.  A parent or legal guardian is required to be with child at the vaccine appointment.  Please click START to move onto the first question.
3-4 Year Old - PFIZER COVID-19 Vaccine
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    For under 3 years of age, please go to our website: www.SkippackPharmacy.com/ToddlerVaccines to schedule.
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    Parental Consent: The patient is a minor and eligible for the Pfizer-BioNTech or Moderna COVID-19 vaccine.• I have the legal authority to consent to the administration of the Pfizer-BioNTech or Moderna COVID-19 vaccine to the minor patient.• I understand that the U.S. Food and Drug Administration (“FDA”) has authorized the emergency use of the Pfizer-BioNTech COVID-19 and Moderna vaccines.• I have been provided access to and read the relevant COVID-19 Vaccine EUA Fact Sheet for Recipients and Caregivers (“Fact Sheet”).• I understand the known and potential risks and benefits of Pfizer-BioNTech or Moderna COVID-19 vaccines and the extent to which such risks and benefits are unknown.• I understand that I have the option to accept or refuse COVID-19 vaccine on behalf of the minor patient.• I understand that the Pfizer-BioNTech and Moderna COVID-19 vaccines are multi-dose vaccine series.• I consent to and authorize all medically necessary treatment in the rare event that the minor patient has a reaction to the vaccine, including but not limited to itching, swelling, fainting, anaphylaxis and other reactions.• The minor patient and I agree that the minor patient will remain in the observation area for the required time period following vaccine dose administration.• I consent to the administration of Pfizer-BioNTech or Moderna COVID-19 vaccine, including any additional required doses to complete the series.
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    IF THE APPOINTMENT SLOTS ARE GRAYED OUT OR DATES ARE UNAVAILABLE, THESE APPOINTMENT TIMINGS ARE ALREADY FILLED. **IF YOU CANNOT MAKE YOUR APPOINTMENT ON A SPECIFIC DAY, THE APPOINTMENT IS VALID AT ANYTIME DURING THE WEEK OF YOUR APPOINTMENT; YOU DO NOT NEED TO EMAIL OR CALL TO RESCHEDULE/CANCEL**
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    Enter without slashes or dashes (numbers only)
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    Please enter your full mailing address (i.e. 2020 Congo Street, Lansdale, PA 19446)
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    Please 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.
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    Max. file size: 10.6MB
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    Cell phone number preferred
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    Enter an email address you check often. In case you don't receive communication from us be sure to check your spam. If you do not have an email address, click next.
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    If you prefer not to answer, click NEXT.
    • American Indian or Alaska Native
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    Once you read the questions below, click the box under YES or NO based on your answer, then click NEXT.
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    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. 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. 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, 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.
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    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) AND Medicare Part D card. If you are not enrolled in Medicare and have non-Medicare insurance, please provide your commercial insurance coverage (RX).
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    **Having this completed will expedite registration.**
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    Max. file size: 10.6MB
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    Drag and drop files here
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    Max. file size: 10.6MB
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    If the card doesn't have a respective number or letters leave that field blank.
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    Please inform the staff member or volunteer at check-in & the vaccinator which option you select.
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    By selecting option 1, 2, or 3 you authorize Skippack Pharmacy to run the tests through your insurance --- you, personally, will not be charged anything for the tests. Only if your insurance covers it, we will have them available for pick up when you come to get your vaccine. If you have Independence Blue Cross or United Health Care prescription coverage (Bin: 015814 or BIN: 610279) these are NOT covered and you will have to order it through your insurance company's website. The masks are free through the government.
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    **Anyone under the age of 18 will need to be accompanied by a parent/legal guardian**
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