2024 - Skippack Pharmacy Vaccine Appointment Registration

2024 - Skippack Pharmacy Vaccine Appointment Registration

***THE NEW 2024-2025 COVID-19 VACCINE IS HERE!*** Thank you for choosing Skippack Pharmacy for your family's vaccination needs. We look forward to the opportunity to serve you & want to help you spend less time in person, so let's take care of intake details for you now! This one universal vaccine registration form is used for all age groups & all vaccines so if you are coming together as a family or setting up multiple appointments, you will need to fill out 1 appointment form per person. Any questions, please reach out to us at clinic@skippackpharmacy.com. ***If you, your child or other individual needing vaccination has a special need or arrangement (disability, needle fear/anxiety, car-bound, etc.), please email clinic@skippackpharmacy.com to schedule a time when one of our special vaccinators is available - for any special circumstance, if your appointment is not pre-arranged & confirmed with a team member via email, our in-store team may not be able to assist you on the day of***
Clinic Location: Immunization Center at Skippack Pharmacy

(4118 W Skippack Pike, Skippack, PA 19474), across Wawa Skippack

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Uninsured or Underinsured? For COVID-19 (Moderna) or Flu (Flucelvax) only, if your insurance does not cover the vaccine at our pharmacy, we have you covered anyways (no cost to you). This is our way of giving back to ensure all irrespective of insurance status are taken care of. Any other vaccine, you may pay out of pocket.

Babies (6 months - 4 years old): All of our babies/toddler clinic dates have been posted. Babies/Toddlers Clinics only occur on dates we have nurses present at the immunization center. Click the respective link appointment link below to see upcoming dates.
Age of Person To Receive Vaccine*
How old is the patient who you are scheduling an appointment for? If over 6 months and under 1 year old, put 0. DO NOT USE DECIMALS. If patient is 1.5 years, old put 1. If patient is 64.5 years old, put 64.
What brings you to Skippack Pharmacy?*

I NEED AN ADULT VACCINE --> I need to sign up for a vaccine for myself or family member (12 YEARS OLD AND UP) ***DO NOT SELECT THIS FOR UNDER 12***I NEED A KIDS VACCINE --> I need to sign up for a vaccine for my child (5 YEARS - 11 YEARS OLD)BABIES/TODDLER VACCINE --> I need a COVID or FLU vaccine for my baby/toddler (6 MONTHS & 4 YEARS OLD)VACCINE NEEDED FOR SCHOOL (VFC) --> I need a non-COVID, non-FLU vaccine for my child that is required for school and my child is uninsured, underinsured, or has Medicaid (between 5 years and 18 years old)
How Did You Hear About Us?*

I Am A Patient of Skippack PharmacyMy DoctorMy Child's PediatricianA Friend / Family MemberA News Website (NP Now, PV Now, Wiss Now)Skippack Pharmacy WebsiteGoogleInstagramFacebookPharmacy Text MessagePharmacy EmailOther
Which ADULT 12+ Vaccine(s) are You Scheduling an Appointment for? Select any which you would like to receive on this visit.*

COVID-19 12+ (Pfizer or Moderna), whichever is available, 2024-25COVID-19 12+ (Moderna only), 2024-25COVID-19 12+ (Pfizer only), 2024-25Novavax 12+, 2024-25Flu Vaccine (65+), 2024-25Flu Vaccine (12-64), 2024-25Flu Vaccine (Flumist Nasal), (5-49), 2024-25RSV (Respiratory Synctial Virus): PREGNANT ONLY -- ABRYSVORSV (Respiratory Synctial Virus): 60+Shingles: SHINGRIX, 1st Dose, 50+Shingles: SHINGRIX, 2nd Dose, 50+, 2-6 months after 1st dosePneumonia: PREVNAR 20, 65+ or 19-64 (Immunocompromised)TDap/Whooping Cough/Tetanus: BOOSTRIX: 18+Hepatitis B: ENGERIX B, 1st Dose, 18+Hepatitis B: ENGERIX B, 2nd Dose (1 month after 1st dose)Hepatitis B: ENGERIX B, 3rd Dose (6 months after 2nd dose)Hepatitis A & B: TWINRIX, 18+
Which KIDS Vaccine(s) are You Scheduling an Appointment for? Select any which you would like to receive on this visit. *If you know your child will need extra attention &/or is very afraid of needles, please email clinic@skippackpharmacy.com & we will help you schedule a vaccine for when a special vaccinator is scheduled**

COVID-19 - KIDS 5-11 (Pfizer or Moderna), whichever is available, 2024-25COVID-19 - KIDS 5-11 (Pfizer only), 2024-25COVID-19 - KIDS 5-11 (Moderna only), 2024-25Flu Vaccine - KIDS 5-11, 2024-25Flu Vaccine (Flumist Nasal), (5-11), 2024-25
Which BABY/TODDLER Vaccine(s) are You Scheduling an Appointment for? Select any which you would like to receive on this visit. If its your child's first flu shot ever & they are between 6 months and 2 years old (they would get 2 doses separated by 1 month), **ON THE FOLLOWING QUESTION, MAKE SURE YOU SELECT AN APPOINTMENT DATE & TIME WHICH MATCHES THE TIME FRAME WRITTEN ON THE VACCINE(S) YOU SELECT - ONLY NURSES SCHEDULED ON CERTAIN SHIFTS CAN ADMINISTER TO THIS AGE GROUP***

Baby Moderna (6mo-4yrs), 2024-25Baby Pfizer (6mo-4yrs old), 2024-25Flu Vaccine (6mo-4yrs), 2024-25
What Dose Number is this for Your Baby/Toddler?*

Unvaccinated - Dose 1 MODERNAUnvaccinated - Dose 2 MODERNAVaccinated - 2024-2025 Booster MODERNA DoseUnvaccinated - Dose 1 PFIZERUnvaccinated - Dose 2 PFIZERUnvaccinated - Dose 3 PFIZERVaccinated - 2024-2025 Booster PFIZER DoseFlu Vaccine - 1st Time in Life (2 doses recommended separated by 1 month)Flu Vaccine - Child Has Received a Flu Vaccine in Prior Years
Baby/Toddler Parent Attestation: By selecting the option below, I attest that I have read the recommended guidelines from the CDC for baby/toddler vaccinations. Link: https://www.cdc.gov/vaccines/covid-19/downloads/covid-19-immunization-schedule-ages-6months-older.pdf --> I also acknowledge I will only come to the appointment at a date/time that a nurse is scheduled. If I have any additional questions, I will seek medical guidance in regards to these vaccines from my child's pediatrician's office & if unsure if my child should receive these vaccines, I will consult with my doctor. For unvaccinated babies, multiple doses are recommended based on the type of the vaccine. While we may not have dates for the following months posted on our site, we are working 1-2 weeks out on scheduling with our nurses so please be sure to check closer to the time your child may be due for an additional dose. Our pharmacists/nurses, the Skippack Pharmacy team CANNOT make any recommendations on which vaccine your baby does or does not need.*

By checking this box, I agree with the statement above.I do not agree with the above (you will not be able to move forward with scheduling an appointment). I will contact my baby's pediatrician and then schedule an appointment.
Which VFC (Vaccine for Children), [Between 3-18 years old, Uninsured/Underinsured/Medicaid] Vaccine Are You Scheduling an Appointment For? **Please be sure to select the correct vaccines which match up to your child's age & please confirm the vaccines you need with your school prior to scheduling an appointment.***

DTaP (DAPTACEL: Diptheria, Tetanus, and Pertussis) - <6 yrs***Td (TENIVAC): Tetanus and Diptheria - 7+ yrs***TDap (ADACEL: Tetanus, Diptheria, Pertussis) - 7+***MMR: Measels, Mumps, Rubella - >1 yr***Hepatitis B (ENGERIX: Hepatitis B) - Any Age***VARIVAX: Varicella (LIVE) Chicken Pox - >1 yr***MCV4 (MENQUADFI: Meningitis) - 2+ yrs***DTaP-IPV-HepB (PEDIARIX: Diptheria, Tetanus, Pertussis, Polio, Hepatitis B) - <6 yrs***POLIO: Poliovirus - 1-19 yr***Flu (FLUCELVAX) - >6mo+Moderna COVID-19 Pediatric - 6mo-11yrsModerna COVID-19 Adult - 12+ yrsPfizer COVID-19 Toddler - 6mo-4yrsPfizer COVID-19 Pediatric - 5yrs-11yrsPfizer COVID-19 Adult - 12+ yrsHepA (HAVRIX: Hepatitis A) - <18 yrsPEDVAXHIB (Haemophilus influenzae type b Vaccine) - <6 yrsGARDISAL (HPV 9 Vaccine) - >9 yrsROTARIX (Rotavirus Oral Vaccine) - <6 mosPneumococcal 15-Valent Conjugate Vaccine
VFC (Vaccines for Children) Attestation: Skippack Pharmacy is 1 of 3 pharmacies in the state of Pennsylvania who has been awarded a Vaccines for Children agreement. With this, if you are under 18 uninsured, underinsured, or on Medicaid and need vaccines for school, please continue below. The vaccines are provided by the Department of Health and are $0; however vaccine administration costs are $20 per vaccine to cover overhead with our supplies and staff. I.e. 1 vaccine = $20, 4 vaccines = $80. By selecting the option below, I attest that I have communicated with my school district nurse or staff to see which vaccine(s) I need for my child. If you are not sure which vaccine your child needs, please do not schedule an appointment until you have that information from your school. Skippack Pharmacy CANNOT make any recommendations on which vaccine your child needs & DOES NOT take any responsibility if you select a vaccine your child does not need.*

By checking this box, I agree with the statement above.I do not agree with the above (you will not be able to move forward with scheduling an appointment). I will contact my school and then schedule an appointment.
Appointment: Please pick a day and time below (to see next month's appointments, click on the down arrow next to the current month) *If you selected multiple vaccines, they will be administered at the same appointment time --- if you are coming with a spouse or family member(s) select the closest appointment together & we will take you in together**
Have you received a Vaccine Through Skippack Pharmacy Before?*

Yes, the patient is in Skippack Pharmacy's system / have received a vaccine(s) at the pharmacy or one of its clinic / there is NO CHANGE in information since the last vaccineYes, the patient is in Skippack Pharmacy's system BUT there has been CHANGE in information (i.e. phone number, email address, RX insurance information, etc)No, this will be the patient's first vaccine through Skippack Pharmacy!Not sure, not sure if the patient has received a vaccine through Skippack Pharmacy before.
Patient Name*

First NameLast Name
Babies/Toddlers Appointment: Please pick a day and time below *If you selected multiple vaccines, they will be administered at the same appointment time --- If you are a parent/caretaker & would also like to receive your FLU and/or COVID-19 vaccine(s) at the same time as your child's appointment, you may. Just fill out this same appointment form & select the same timing or closest timing & you can get vaccinated together* Since you are selecting an appointment for a BABY/TODDLER, if you end up cancelling or rescheduling, that can only happen on a date a nurse is here (date/times you'll see below). For November dates, please fill out our interest form to be notified. If you come in on another date/time that a nurse is not present, we unfortunately will not be able to administer a vaccine to your toddler/baby.*
Patient Date of Birth*

MonthDayYear
Date
Gender at Birth*

MaleFemaleOther
Email of Patient (or caregiver filling this out) --- preferably non-comcast.net email addresses as Comcast has been filtering our emails. If it is a comcast.net email address & you sign up, if you see the THANK YOU page after submitting, your appointment is confirmed, you do not need to call to see if it is confirmed.*
example@example.com
Phone Number*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Demographic Information (Optional)

Please answer "Yes" or "No" to the questions below concerning the patient's Medical History. The caregiver may fill this out on behalf of the patient. If unsure or you answer "Yes" to any of these and have concerns, please consult your doctor prior to receiving a vaccine. To save you time in person, we ask these questions now. If the answer is No for ALL of the questions, click the NO on the last field.*

	Yes	No
If your answer to ALL of the questions below is no -> SELECT NO --> and can move on to the next question.
Do you have allergies or reactions to any foods, medications, vaccines or latex? (For example: eggs, gelatin, neomycin, thimerosal, etc.) or 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?
Have you ever had a serious reaction after receiving a vaccination? Do you have a history of fainting, particularly with vaccines? Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
Have you had a seizure or a brain or other nervous system problem or Guillain Barre Syndrome?
Have you ever had a severe allergic reaction after receiving a vaccine?
Are you moderately or severely immunocompromised from a medical condition/immunosuppressive therapy, including but 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?
Are you pregnant or do you plan on becoming pregnant in the next 30 days?
Have you received a COVID-19 vaccine in the past 2 months? Have you been treated with antibody therapy (monoclonal antibodies or convalescent plasma) specifically for COVID-19?
Do you have a history of myocarditis (inflammation of the heart muscle), pericarditis (inflammation of the lining around the heart), multisystem inflammatory syndrome (MIS-C or MIS-A), or thrombocytopenia syndrome (TTS)? Do you have a bleeding disorder or take blood thinners such as Warfarin/Coumadin?

Coverage: I understand that I will be receiving a vaccine through Skippack Pharmacy. On any statement received from insurances, the pharmacy's legal name, "Yogikrupa Health, LLC," may appear. By registering, I authorize Skippack Pharmacy to bill my prescription insurance for the cost of the vaccine and cost of administration. Vaccines are no longer provided by the Federal or State Government & is purchased by Skippack Pharmacy from the manufacturers and thus we need to bill your insurance. If your prescription benefit does not cover your vaccine (for flu & COVID-19), there will be a $20 administration fee; however, we will cover the cost of the vaccine.*

I have Medicare (Medicare Part B and/or Part D is used based on type of vaccine)I have only NON-Medicare insurance (i.e. commercial plan, Tricare, etc.)I have Medicaid insurance (i.e. Keystone First, Health Partners, etc.)I do not have prescription insurance & would like to receive a flu vaccine.I do not have prescription insurance & would like to receive a COVID-19 vaccine (Moderna only).I do not have prescription insurance & will pay out of pocket for the cost of the vaccine (any vaccine outside of Flulaval & Moderna.Vaccine For Children - I am under 18 & do not have prescription insurance, Medicare, Medicaid, or any commercial or government-funded health benefit plan. I will pay $20 per vaccine for the administration fee.
PLEASE VIEW THE BELOW EXAMPLES OF MEDICARE CARDS SO YOU KNOW WHAT TO UPLOAD AND/OR WHAT INFORMATION TO INPUT (PROVIDING THIS INFORMATION IN ADVANCE WILL HELP YOU SAVE TIME ON THE DAY/TIME OF YOUR VACCINE APPOINTMENT):

Medicare Recipients - Which Card Do I Use?

Medicare B or Medicare Advantage: Flu, COVID-19, Pneumonia ($0 copay)

Medicare D (RX card): Shingles & RSV ($0 copay)

This is what Medicare B (red, white, blue card) looks like for MOST people. We use this card to process Flu, Pneumonia, and COVID-19 vaccines with $0 copay.
In some cases, if you received Medicare Part B (HMO) through retirement benefits (i.e. Verizon employees), you may have a different card (i.e. United Healthcare Part B or Aetna Part B - examples below). This is the card that we use for SOME people. We will use this card to process Flu, Pneumonia, and COVID-19 vaccines with $0 copay.
In some cases, you may have a Medicare Advantage Card (i.e. Keystone 65). This is the card that we use for SOME people. We will use this card to process Flu, Pneumonia, and COVID-19 vaccines with $0 copay.
MEDICARE CARD UPLOAD: 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). IF you have Medicare Part B through AETNA HMO, UNITED HEALTHCARE HMO (i.e. Verizon employees), or any other Part B, please upload that, too. If you have difficulties uploading it here, please bring with you to your vaccine appointment. ***IF you have uploaded this in the past or provided it at check-in to the Skippack Pharmacy team or volunteers & there are no changes, you DO NOT need to do this again.***

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PRESCRIPTION RX CARD UPLOAD: Please click "Upload Image or File" and upload copies of those cards herein and then click "Next." For most insurances, our system can pull up your information but for some (including CAPITALRX), our system cannot pull it automatically. Please ensure the card has the letters "RX" on it. If you have difficulties uploading it here, please bring with you to your vaccine appointment.***IF you have uploaded this in the past or provided it at check-in to the Skippack Pharmacy team or volunteers & there are no changes, you DO NOT need to do this again.***

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Please input the numbers/letters from your Prescription Insurance card, or bridge voucher, or if applicable, Medicare B Card, below. IF you have Medicare Part B through AETNA HMO, UNITED HEALTHCARE HMO (i.e. Verizon employees), or any other Part B, please put that card info 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. If your card does not have one of the below, please leave that field blank. If you do not have insurance, put in the last 4 of your SSN. After filling it out, hit "Next." Not providing this informaton now could delay your registration on-site.
Skippack Pharmacy is on a mission to get more Narcan (used for opioid overdose reversal) into the community to help save others lives. While you or someone you may know may not need it, this could save a life for a neighbor, someone on the street in passing, or anyone else. Would you like to receive a Narcan during your vaccine appointment? Irrespective of whether you have insurance or not, there will be no charge to you. If you choose to donate it, there will be donation bins at the pharmacy.*

YES - I would like a Narcan to keep to potentially save a lifeNO - I would not like a Narcan
What is your preferred site of administration for the vaccine(s)?*

Left ArmRight ArmOne in the left and one in the right (ONLY applies if you are getting more than one vaccine)Left Leg (Babies (under 3))Right Leg (Babies (under 3))One in the left and one in the right (ONLY applies if baby is getting more than one vaccine)Nasal
Do you have any comments, feedback, etc. to help us improve? LEAVE BLANK IF NONE & skip to last questions
CONSENT & WAIVER: By clicking the box below, I am indicating my consent and agree my electronic signature is the legal equivalent of my manual signature on this Agreement. If I am signing on behalf of another individual (including a minor), I attest that I have the authority to do so. Please note that patients under 18 must have the consent of a parent or guardian. If I am receiving a COVID-19 vaccine dose, I attest I am eligible for that dose according to current recommendations from the CDC.*
Signature Of Parent (if under 18) or Patient*

Clear
Date Signed
Should be Empty: