Peter Becker

Peter Becker Community - Vaccine Registration

Thank you for choosing Skippack Pharmacy for your 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!
Event Name: Peter Becker Community - Vaccine Clinic

Four Clinic Times/Locations:

Tuesday, October 6th, 2026
- 9:30-11:30 AM at the ACC of Maplewood Estate
- 1:30-3:30 PM at Orchid Terrace of Campus Center
Tuesday, October 20th, 2026
- 9:30-11:30 AM at Orchid Terrace of Campus Center
- 2:00-4:00 PM at the ACC of Maplewood Estate
Have you received a vaccine through Skippack Pharmacy before? Either at Peter Becker or at Skippack Pharmacy?
Where do you reside at Peter Becker?
Patient Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
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
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender at Birth
Which Vaccine(s) Should I Get To Stay Protected?

Flu - Annual flu vaccine

COVID-19 (Pfizer or Moderna, any age) - COVID-19 vaccine for any age

You may get up to 2 vaccines on one visit or can separate your vaccines, as well. You can get multiple vaccines in 1 arm or separate them to each arm (just let the vaccinator know).

If you are unsure of which vaccine you should get, speak to your healthcare provider or have a Skippack Pharmacy clinic team member do a thorough review of your vaccine history by emailing clinic@skippackpharmacy.com.
Which Vaccine(s) are You Scheduling an Appointment for? Select any which you would like to receive on this visit.
Which date do you plan on attending?
Appointment
Appointment

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.

Rows	Yes	No
Are you 65+ or have a condition that puts you at high risk for severe outcomes from COVID-19 virus
Allergic to gelatin, latex, yeast, neomycin or any vaccine ingredient
Serious reaction after getting a vaccine
Dizzy or faint before, during or after an immunization
Seizure or other brain or nervous system condition, including Guillain-Barré syndrome (GBS)
Taken medications that affect the immune system or had radiation treatment in the last 6 months
Weakened immune system because of active cancer, HIV/AIDS, transplant or other medical condition
Diagnosed with a heart condition or Multisystem Inflammatory Syndrome (MIS-A or MIS-C)

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.
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 and COVID-19 ($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 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 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.

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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.

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Please input the numbers/letters from your Prescription Insurance card, or if applicable Medicare D Card/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 information now could delay your registration on-site.
What is your preferred site of administration for the vaccine(s)?
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
Date Signed
Should be Empty:

Peter Becker Community - Vaccine Registration