Methacton High School (10-9-2025) - Vaccine Appointment Registration

Event Name: Family Vaccine Clinic

Location: Methacton High School (1005 Kriebel Mill Rd, Eagleville, PA 19403) - in the Gymnasium

Date & Time: Thursday October 9, 2025 3:00PM-7:00PM

Uninsured or Underinsured? Skippack Pharmacy is here to help you regardless of insurance status. There will be NO COST to you.

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?

Have you received a Vaccine Through Skippack Pharmacy Before?

How Did You Hear About Us?

Which Vaccine(s) Should I Get To Stay Protected?

COVID-19 (Pfizer or Moderna, 12+)

COVID-19 (Kids Moderna, 3-11), (Kids Pfizer, 5-11)

COVID-19 (Toddler Moderna, 6mo-2years old)

Flu (Flucelvax, ages 3–64) – Annual flu shot for everyone 3 years and older.

Senior Flu (Fluad, 65+) – Annual flu shot, specially designed for stronger protection in seniors.

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. You can select up to 2 on one visit.

What Dose Number is this for Your Baby/Toddler?

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. 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. Our pharmacists/nurses, the Skippack Pharmacy team CANNOT make any recommendations on which vaccine your baby does or does not need.

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.**

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.

Normal Clinic Hours:
Monday-Friday 10AM-6PM, Saturday 10AM-3PM

*We take the last appointment 15 minutes before we close*

Extended Clinic Hours in SEPTEMBER Only (by appointment only):

To better accommodate families with children, those who work later, or may not be able to come in during the day time. You will see these later time offerings available on the appointment scheduler and will be able to pick a time accordingly.

SEPTEMBER:

Monday 10AM-7PM

Wednesday & Friday 10AM-6PM

Tuesday & Thursday 10AM-7PM

Saturday 10AM-3PM

Due to a Jotform limitation, you may see the extended time slots available outside of the above after September; however, please do not select them, as our clinic will resume normal hours in October and forward closing at 6PM.

If you have a special circumstance where you need a later vaccination in October onwards, please email us at clinic@skippackpharmacy.com and we'll work with you to do our best to accomodate.

NONE AVAILABLE CURRENTLY - PLEASE SIGN UP ON OUR INTEREST FORM. Babies/Toddlers Appointment: Please pick a day and time below. We currently only have 2024-25 Babies/Toddlers Moderna & 2025-26 Flu vaccine. 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*

Patient Name

First NameLast Name

Patient Date of Birth

Date

Gender at Birth

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

Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Appointment (if a time slot is not available, you will see it missing from below). Rest assured, if you are coming as a group, please select the closest time slots and come together.

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, 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.***

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.***

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.

Would you like Skippack Pharmacy to send you COVID-19 tests and/or Narcan at NO COST to you? If you select, yes, we will process these through insurance (if applicable) and mail them directly to your home at no charge. Skippack Pharmacy is on a mission to keep our community protected during respiratory season with COVID-19 tests, and beyond with Narcan, a life-saving medication that can reverse opioid overdoses. Even if you or your loved ones don’t personally need Narcan, having it available could help save the life of a neighbor, a friend, or someone you meet in the community. 👉 Learn more about Narcan and our program: www.SkippackPharmacy.com/narcan [there is no cost to you whether you have insurance or not]

What is your preferred site of administration for the vaccine(s)?

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

Date Signed

Methacton High School - Vaccine Registration