Home-Visit Vaccine Appointment Sign-Up
Thank you for supporting local business and choosing Skippack Pharmacy! Please fill out this form in its entirety and to the best of your ability. All information collected on this form is HIPAA-protected and will not be shared with any person or organization outside of Skippack Pharmacy and your insurance. All insurance information collected is solely for claim-processing purposes and will only be used to bill your insurance for the vaccines. If you have any questions about this form, please contact our team by phone at 610-584-6979 or email at clinic@skippackpharmacy.com
Let's Get Started!
First, let's find out who you are and learn a little more about the vaccines you are inquiring.
Who is filling out this form?
*
I am the patient filling this form out for myself
I am a family member and/or caregiver filling this form out for a homebound patient
I am a physician/other provider requesting for a homebound patient
Current PATIENT Status
*
The patient has received vaccines from Skippack Pharmacy in the past
This is the patient's first time receiving vaccines at-home from Skippack Pharmacy
Name of PATIENT RECEIVING VACCINE
*
First Name
Last Name
PATIENT's Date of Birth
*
-
Month
-
Day
Year
Date
Patient Gender
*
Male
Female
Other
Address where you'd like to RECEIVE VACCINE
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
*
-
Area Code
Phone Number
Email
example@example.com
Which Vaccine(s) are you scheduling an appointment for?
*
COVID-19, (Moderna) Vaccine, Age12+ (2025/26)
COVID-19, Corminaty (Pfizer) Vaccine, Age 12+ (2025/26)
Flu, FLUCELVAX, Ages 3-64
Flu, FLUAD, Age 65+
RSV (Respiratory Synctial Virus), Age 60+
Shingles, SHINGRIX, Age 50+ -- FIRST DOSE
Shingles, SHINGRIX, Age 50+ -- SECOND DOSE (2-6 mo. after 1st dose)
Pneumonia, Age 50+
Hepatitis B, ENGERIX B, Age 18+ -- FIRST DOSE
Hepatitis B, ENGERIX B, Age 18+ -- SECOND DOSE (1 mo. after 1st dose)
Hepatitis B, ENGERIX B, Age 18+ -- THIRD DOSE (6 mo. after 2nd dose)
Hepatitis A & B, TWINRIX, Age 18+
Tdap, BOOSTRIX, Age 10+
Insurance Information
All information collected on this form is HIPAA-protected and will not be shared with any person or organization outside of Skippack Pharmacy and your insurance. All insurance information collected is solely for claim-processing purposes and will only be used to bill your insurance for the vaccines.
What insurance coverage do you have?
*
Medicare
I only have non-Medicare insurance
I do not have insurance & will pay out of pocket.
MEDICARE CARD: If able, upload a copy of your Medicare B card (red, white, and blue) or Medicare Part D card. If unable, skip this.
Browse Files
Cancel
of
NON-MEDICARE INSURANCE: If able, upload a copy of your PRESCRIPTION Insurance Card
Browse Files
Cancel
of
RX BIN
RX PCN
RX GROUP
MEMBER ID
MEDICARE B # OR PART D #
Last 4 Digits of PATIENT'S SSN
Back
Next
Screening & Consent
Do you have any allergies to any medications, food, vaccine components, or latex?
*
Yes
No
Have you ever had a serious allergic reaction to a vaccine?
*
Yes
No
Do you have any long-term health problems with heart disease, lung disease, asthma, kindey disease, metabolic disorders (e.g. diabetes), anemia, or any other health or blood disorders?
*
Yes
No
Do you current have cancer, leukemia, AIDS, or any other immune system conditions?
*
Yes
No
Do you take cortisone, prednisone, or other steriods OR anti-cancer medications OR do you have a history of radiation treatments?
*
Yes
No
Do you have a history of seizure or brain disoders OR any other nervous system condition?
*
Yes
No
Within the past year, have you received a blood (or blood product) transfusion, or been given immune (gamma) globulin or any anti-viral drug?
*
Yes
No
Are you currently pregnant, trying to become pregnant, or is there a chance that you could become pregnant within the next month?
*
Yes
No
If you answered yes to any of the above screening questions, please specify/clarify below.
Consent and waiver: I consent to the staff to administer the medication(s) mentioned below. I have reviewed the vaccine information sheet (s) for the respective vaccine I will be receiving and understand the benefits and risks of receiving this vaccine and choose to assume this risk. I fully release and discharge the standing order physician (Dr. Shaun Gill) 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, 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 acknowledge that I have read & reviewed the above statements and give my consent.
Signature
Submit
Should be Empty: