Pediatric COVID-19 Vaccine Interest Form

Baby/Toddler COVID-19 Vaccine Interest

Skippack Pharmacy & the COVID Task Force have been at the forefront of vaccine administration over the past 2 years through providing vaccines at off-site clinics at schools, churches, pop-up clinics and at the pharmacy. Please fill out this interest form if your baby (under 3) is in need of a baby COVID vaccine. Based on when we get vaccines in / nurses availability, we will reach out to you to inform you of upcoming clinics.
Your Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Your Email Address*
An email address we will send the appointment links & clinic information to.
Your Baby/Toddler's Name*

First NameLast Name
Your Baby/Toddler's Age
Which dose of vaccine is this for your baby?

Unvaccinated - Dose 1 MODERNAUnvaccinated - Dose 2 MODERNAVaccinated - 2024-25 Booster MODERNA DoseUnvaccinated - Dose 1 PFIZERUnvaccinated - Dose 2 PFIZERUnvaccinated - Dose 3 PFIZERVaccinated - 2024-25 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
PFIZER (12+): How many people in your family 12+ would want the NEW 2023-2024 Pfizer COVID-19 Vaccine through Skippack Pharmacy:
PFIZER (5 Years Old-11 Years Old): How many people in your family are 5 years-11 years old who you would want to get the NEW 2023 Pfizer COVID-19 Vaccine through Skippack Pharmacy:
PFIZER (6 Months-4 Years Old): How many people in your family are 6 months-4 years old who you would want to get the NEW 2023 Pfizer COVID-19 Vaccine through Skippack Pharmacy:
MODERNA (12+): How many people in your family are 12+ would want the NEW 2023 Moderna COVID-19 Vaccine through Skippack Pharmacy
MODERNA (3 Years Old-11 Years Old): How many people in your family are 3 years-11 years old who you would want to get the NEW 2023 Moderna COVID-19 Vaccine through Skippack Pharmacy:
MODERNA (6 Months-2 Years Old): How many people in your family are 6 months-2 years old who you would want to get the NEW 2023 Moderna COVID-19 Vaccine through Skippack Pharmacy:
How many children in your family would you want the FLU vaccine ALONG WITH the new COVID-19 vaccine through our pharmacy/clinic? *YOU CAN RECEIVE BOTH SHOTS AT ONE APPOINTMENT IF YOU'D LIKE**
How many people in your family would want the FLU vaccine SEPARATE than the booster but through our pharmacy/clinic? We will also be hosting separate flu shot clinics where your entire family can come together*
What city do you live in?
Although you selected numbers above do you have a specific brand preference for your child or okay with receiving either vaccine?*

Pfizer onlyModerna onlyI am indifferent & okay getting whichever vaccine is available
Where would you prefer to receive the vaccine?

School District ClinicChurch ClinicTownship Building ClinicSkippack Pharmacy Immunization Center
What day(s) of the week typically work best for you?
Can select multiple if multiple apply. This will help us with timing clinics.
Please put anything else we should know or you'd like to tell us below. Thank you!
What city do you live in?
Should be Empty:

Baby/Toddler COVID-19 Vaccine Interest