Superheroes Vaccine Tour (Thurs 8/11/22) - North Wales Borough Hall

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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? 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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Which vaccine are you scheduling an appointment for?
Pfizer 1st Dose (TODDLER 6 Months-2 Year Old) - DOSE 1
Pfizer 2nd Dose (TODDLER 6 Months-2 Year Old) - given 3 weeks after 1st dose - DOSE 2
Pfizer 3rd Dose (TODDLER 6 Months-2 Year Old) - given 2 months after 2nd dose - DOSE 3
Moderna 1st Dose (TODDLER 6 Months-2 Year Old) - DOSE 1
Moderna 2nd Dose (TODDLER 6 Months-2 Year Old) --> given >28 days after 1st dose - DOSE 2
Pfizer 1st Dose (TODDLER 3-4 Year Old) - DOSE 1
Pfizer 2nd Dose (TODDLER 3-4 Year Old) - given 3 weeks after 1st dose - DOSE 2
Pfizer 3rd Dose (TODDLER 3-4 Year Old) - given 2 months after 2nd dose - DOSE 3
Moderna 1st Dose (TODDLER 3-5 Year Old) - DOSE 1
Moderna 2nd Dose (TODDLER 3-5 Year Old) --> given >28 days after 1st dose - DOSE 2
Moderna 1st Dose (PEDS 6-11 year old)
Moderna 2nd Dose (PEDS 6-11 year old) --> given >28 days after 1st dose
Moderna 1st Dose (12+ year old)
Moderna 2nd Dose (12+ year old) --> given >28 days after 1st dose
Moderna 3rd Dose (Booster) (18+ year old) --> given >5 months after 2nd dose
Moderna 4th Dose (2nd Booster) (50+ year old) --> given 4 months after 1st booster
Moderna 3rd Dose (6-11 year old) - IMMUNOCOMPROMISED ONLY --> given >28 days after 2nd dose
Moderna 3rd Dose (12+ year old) - IMMUNOCOMPROMISED ONLY (will receive 0.5ml) --> given >28 days after 2nd dose
Moderna 4th Dose (Booster) (18+ year old) - IMMUNOCOMPROMISED ONLY --> given 3 months after the 3rd dose
Moderna 5th Dose (2nd Booster) (18+ year old) - IMMUNOCOMPROMISED ONLY --> given 4 months after 4th dose
Pfizer 1st Dose (5-11 year old)
Pfizer 2nd Dose (5-11 year old) --> given >21 days after 1st dose - DOSE 2
Pfizer 3rd Dose (5-11 year old) --> given 5 months after 2nd dose - DOSE 3
Pfizer 1st Dose (12+ year old)
Pfizer 2nd Dose (12+ year old) --> given >21 days after 1 dose
Pfizer 3rd Dose (Booster) (12+ year old) --> given >5 months after 2nd dose
Pfizer 4th Dose (2nd Booster) (50+ year old) --> given >4 months after 1st booster
Pfizer 3rd Dose (5-11 year old) - IMMUNOCOMPROMISED ONLY --> given >28 after 2nd dose
Pfizer 4th Dose (Booster) (5-11 year old) - IMMUNOCOMPROMISED ONLY --> given >3 months after 3rd dose
Pfizer 4th Dose (Booster) (12+ year old) - IMMUNOCOMPROMISED ONLY --> given >3 months after 3rd dose
Pfizer 5th Dose (2nd Booster) (12+ year old) --> IMMUNOCOMPROMISED ONLY --> given >4 months after 1st booster (4th Dose)
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Select an appointment time for your COVID-19 Vaccine* This field is required.IF THE APPOINTMENT SLOTS ARE GRAYED OUT OR DATES ARE UNAVAILABLE, THESE APPOINTMENT TIMINGS ARE ALREADY FILLED. **IF ALL THE SLOTS ARE FILLED, PLEASE EMAIL COVID@SKIPPACKPHARMACY.COM SO WE MAY OPEN ADDITIONAL SLOTS**
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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)
MMDDYYYY
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Vaccine Recipient's Gender at Birth* This field is required.
Please Select
Please Select
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
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State Initials
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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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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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 AddressEnter 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.
I.e. jonathansmith@gmail.com
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Demographic InformationIf you prefer not to answer, click NEXT.
Please Select
Please Select
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Other Race
Race
Please Select
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Ethnicity
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COVID-19 Vaccine Screening Questions* This field is required.Once you read the questions below, click the box under YES or NO based on your answer, then click NEXT.
YesNo
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? Had you ever had a severe allergic reaction after receiving a COVID-19 vaccine? Have you ever had a severe allergic reaction after receiving another vaccine or injectable medication? Have you ever had a severe allergic reaction after receiving Polyethylene Glycol? Are you currently pregnant or breastfeeding? Do you have a bleeding disorder or are you taking a blood thinner? Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days? 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? Do you have a history of Guillain-Barré syndrome (GBS)? Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)? 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.
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? Had you ever had a severe allergic reaction after receiving a COVID-19 vaccine? Have you ever had a severe allergic reaction after receiving another vaccine or injectable medication? Have you ever had a severe allergic reaction after receiving Polyethylene Glycol? Are you currently pregnant or breastfeeding? Do you have a bleeding disorder or are you taking a blood thinner? Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days? 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? Do you have a history of Guillain-Barré syndrome (GBS)? Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)? 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.
YesNo
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Consent* This field is required.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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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) AND Medicare Part D card. If you are not enrolled in Medicare and have non-Medicare insurance, please provide your commercial insurance coverage (RX).
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, 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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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.
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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.
RX BIN
RX PCN
RX Group
Member ID
If 65+ or disabled, Medicare B # from your Medicare B Card (red, white and blue card)
If no active RX insurance, last four digits of your social security number
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Which arm (or leg - Under 3) would you like your child to receive the vaccine?Please inform the staff member or volunteer at check-in & the vaccinator which option you select.
Left Arm
Right Arm
Left Leg
Right Leg
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Interested in Receiving Up To 8 At-Home COVID Tests for $0?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 FOR ME - Yes, I'd like 8 At-Home COVID Tests at no cost.
COVID TESTS FOR ME - 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.
DONATE MY TESTS - No, I do not need them; however, please run them through and donate them to a homeless shelter, domestic abuse center, or a family in need on my behalf.
NO - I am not interested.
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Signature of Person to Receive Vaccine OR Parent/Guardian* This field is required.**Anyone under the age of 18 will need to be accompanied by a parent/guardian**
Clear
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Date Signed
Date
Month
Day
Year
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