Monkeypox Vaccine

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Unique ID
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Were you exposed to a person with a Monkeypox infection within the past 14 days? (Examples include living with the individual, sexual activity with the individual, or direct skin to skin contact with the individual).
Yes
No
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What was the last date of exposure?
Date
Month
Day
Year
4
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? Has the vaccine recipient tested positive for COVID-19 within the last 14 days?
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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Which Vaccine are you scheduling?* This field is required.
Monkeypox Vaccine Dose 1
Monkeypox Vaccine Dose 2
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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.Please enter your birthdate as DD/MM/YYYY (Day, Month, Year).
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Vaccine Recipient Gender* This field is required.
Please Select
Please Select
Male
Female
Transgender
Non-binary
Other
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Vaccine Recipient Physical Address* This field is required.Please enter your full mailing address (i.e. 2020 Serenity Street, Lansdale, PA 19446)
Street Address
Street Address Line 2
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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.
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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. If you do not have an email address, please click next.
I.e. jonathansmith@gmail.com
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Primary Care Provider Name* This field is required.What is the name of your family doctor or family doctor group? If unknown, write UNKNOWN, if you don't have one, write NONE
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Immunization Screening Questions* This field is required.Answering yes to any of the below questions does not exclude you from receiving the vaccine; however, will give additional information to our team to better serve you.
Yes
No
Do you have any allergies to medications, food, a vaccine component, or latex? Have you ever had a serious allergic reaction to a vaccine? Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorders? Do you have cancer, leukemia, AIDS, or any other immune system problem? Do you take cortisone, prednisone, other steroids, or anti-cancer drugs, or have you had radiation treatments? Have you had a seizure or a brain or other nervous system problem? During the past year, have you received a transfusion or blood or blood products, or been given immune (gamma) globulin or an anti-viral drug? For women: are you pregnant or is there a chance you could become pregnant during the next month? IF YOU ANSWER YES, PLEASE INFORM OUR VACCINE STAFF UPON ARRIVAL TO THE PHARMACY.
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Have you received any vaccine in the past 4 weeks?
Row 1, Column 0
Row 1, Column 1
Do you have an allergy to gentamicin, ciprofloxacin or chicken or egg protein? IF YOU ANSWER YES, PLEASE INFORM OUR VACCINE STAFF UPON ARRIVAL TO THE PHARMACY.
Row 2, Column 0
Row 2, Column 1
Do you have any allergies to medications, food, a vaccine component, or latex? Have you ever had a serious allergic reaction to a vaccine? Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia, or other blood disorders? Do you have cancer, leukemia, AIDS, or any other immune system problem? Do you take cortisone, prednisone, other steroids, or anti-cancer drugs, or have you had radiation treatments? Have you had a seizure or a brain or other nervous system problem? During the past year, have you received a transfusion or blood or blood products, or been given immune (gamma) globulin or an anti-viral drug? For women: are you pregnant or is there a chance you could become pregnant during the next month? IF YOU ANSWER YES, PLEASE INFORM OUR VACCINE STAFF UPON ARRIVAL TO THE PHARMACY.
Have you received any vaccine in the past 4 weeks?
Do you have an allergy to gentamicin, ciprofloxacin or chicken or egg protein? IF YOU ANSWER YES, PLEASE INFORM OUR VACCINE STAFF UPON ARRIVAL TO THE PHARMACY.
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
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Consent* This field is required.Consent and waiver: I consent to the staff to administer the medication(s) mentioned below. I have reviewed the vaccine information sheet (s) and understand the benefits and risks of receiving this medication and choose to assume this risk. I fully release and discharge the standing order physician (Dr. Zane Gates) and the pharmacy, its affiliations and their officers, and employees from any illness, injury, loss, or damage that may result there from. I assign payment of authorized insurance benefits due to me to be paid to the pharmacy and will pay any copay or deductible that result. I consent the release of medical information when necessary for billing, reimbursement, and medical protocol. I also allow for the pharmacy to report any medications received to the appropriate state vaccine registry. I agree to stay in the vaccine administration area for fifteen (15) minutes or longer if indicated by the vaccine administrator after receiving my vaccine to ensure that no immediate adverse reactions occur. 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).
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Coverage InformationI understand that I will be receiving the Flu vaccine through Skippack Pharmacy and my insurance (RX, Medicare D, or Medicare B) will be billed for the cost of the medication and administration.
I have Medicare
I have only non-Medicare insurance
I do not have insurance & will pay out of pocket.
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This is what a Medicare B Card Looks Like, click "NEXT"The highlighted beige field is your Medicare number we'll need.
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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, upload your Medicare Part D card. If you have difficulty uploading it in which case, we will ask for this at check-in.**Having this completed will expedite registration.**
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Max. file size: 10.6MB
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This is what a Prescription RX Card Looks Like, click "NEXT"Notice how their is a logo or letters on it somewhere that says the letters "RX" --- if it doesn't have RX written on it, you are likely looking at your medical card. We do not need that.
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RX INSURANCE CARD: For anyone with a prescription RX insurance card, please click "Upload Image or File" and upload copies of those cards herein and then click "Next." Please ensure the card has the letters "RX" on it. Click "Next" if you have difficulty uploading it in which case, we will ask for this at check-in.**Having this completed will expedite registration.**
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 RX card and if applicable, Medicare B Card, below. You are looking at your prescription card if it has the letters RX on it otherwise, you are likely looking at your medical card. No insurance, put the last four digits of your social security number in the last box. After filling it out, hit "Next."If the card doesn't have a respective number or letters leave that field blank.
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Which arm would you like to receive the vaccine in?Please inform the staff member or volunteer at check-in & the vaccinator which option you select.
Left
Right
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Interested in Receiving Up To 8 At-Home COVID Tests for $0?* This field is required.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.
COVID TESTS ONCE - Yes, I'd like 8 At-Home COVID Tests at no cost.
COVID TESTS MONTHLY - Yes, I'd like 8 At-Home COVID Tests at no cost & please mail me an additional 8 tests each month while my insurance covers it.
NO - I am not interested.
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Signature of Person to Receive Vaccine* This field is required.or parent if child
Clear
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Date Signed
Date
Month
Day
Year
Should be Empty: