Methacton Vaccine Clinic - Methacton High School (Oct 21, 2024)

Event Name: Family Vaccine Clinic

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

Date & Time: Monday October 21, 2024 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*

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.

Which Vaccine(s) are You Scheduling an Appointment for? Select any which you would like to receive on this visit.*

NEW 2024-2025 ADULT COVID-19, Pfizer OR Moderna, 12+ - I AM OKAY WITH WHICHEVER IS AVAILABLENEW 2024-2025 ADULT COVID-19, Comirnaty (Pfizer) Vaccine/Booster, 12+**NEW 2024-2025 ADULT COVID-19, Spikevax (Moderna) Vaccine/Booster, 12+Flu, FLUAD, 65+Flu, FLUCELVAX, 6 Months-64 YrsNEW 2024-2025 KIDS COVID-19, Moderna, (6 Months - 11 Yrs ONLY)NEW 2024-2025 TODDLER COVID-19, Pfizer (6 Months-4 Yrs)NEW 2024-2025 KIDS COVID-19, Pfizer (5 Yrs - 11 Yrs)

Appointment: Please pick a day and time below *If you selected multiple vaccines, they will be administered at the same appointment time --- if you are coming with multiple children or family member(s) select the closest appointment together & we will take you in together**

Have you received a Vaccine Through Skippack Pharmacy Before?*

Yes, I am in Skippack Pharmacy's system / have received a vaccine(s) at the pharmacy or one of its clinic / there is NO CHANGE in information since my last vaccineYes, I am in Skippack Pharmacy's system BUT there has been CHANGE in my information (i.e. phone number, email address, insurance information, etc)No, this will be my first vaccine through Skippack Pharmacy!Not sure, I am not sure if I have received a vaccine through Skippack Pharmacy before.

Patient Name*

First NameLast Name

Patient Date of Birth*

Date

Gender at Birth

MaleFemaleOther

Email of Patient (or caregiver filling this out)*

example@example.com

Phone Number*

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please answer "Yes" or "No" to the questions below concerning your Medical History. To save you time in person, we ask these questions now.*

	Yes	No
If your answer to ALL of the questions below is no -> SELECT NO --> and can move on to the next question.
Have you ever had a serious reaction after receiving a vaccination? Do you have a history of fainting, particularly with vaccines? Has any physician or other healthcare professional ever cautioned or warned you about receiving certain vaccines or receiving vaccines outside of a medical setting?
Have you had a seizure or a brain or other nervous system problem or Guillain Barre Syndrome?
Have you ever had a severe allergic reaction after receiving a vaccine?
Do you have a history of myocarditis (inflammation of the heart muscle), pericarditis (inflammation of the lining around the heart), multisystem inflammatory syndrome (MIS-C or MIS-A), or thrombocytopenia syndrome (TTS)? Do you have a bleeding disorder or take blood thinners such as Warfarin/Coumadin?
Are you moderately or severely immunocompromised from a medical condition/immunosuppressive therapy, including but 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?
Are you pregnant or do you plan on becoming pregnant in the next 30 days?
Do you have allergies or reactions to any foods, medications, vaccines or latex? (For example: eggs, gelatin, neomycin, thimerosal, etc.) or 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?

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 insurance for the cost of the vaccine and cost of administration. Vaccines are no longer provided by the Federal or State Government & is purchased by Skippack Pharmacy from the manufacturers and thus we need to bill your insurance.

I have Medicare (Medicare Part B and/or Part D is used based on type of vaccine)I have only NON-Medicare insurance (i.e. commercial plan, Tricare, etc.)I have Medicaid insurance (i.e. Keystone First, Health Partners, etc.)I do not have insurance & would like to receive a flu vaccine (Flulaval only) at no cost to meI do not have insurance & would like to receive a COVID-19 vaccine (Moderna only) at no cost to me

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 OR BRIDGE VOUCHER UPLOAD: Please click "Upload Image or File" and upload copies of those cards (or voucher) herein and then click "Next." 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 bridge voucher, or if applicable, 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. After filling it out, hit "Next."

Skippack Pharmacy is on a mission to get more Narcan (used for opioid overdose reversal) into the community to help save others lives. While you or someone you may know may not need it, this could save a life for a neighbor, someone on the street in passing, or anyone else. Would you like to receive a Narcan during your vaccine appointment? Irrespective of whether you have insurance or not, there will be no charge to you. If you choose to donate it, there will be donation bins at the pharmacy you may drop it into.

YES - I would like a Narcan to keep to potentially save a lifeNO - I would not like a Narcan

Which arm (leg-babies) would you like to receive your vaccine(s) in?*

Left ArmRight ArmOne in the left and one in the right (ONLY applies if you are getting more than one vaccine)Left Leg (Babies (under 2))Right Leg (Babies (under 2))One in the left and one in the right (ONLY applies if baby is getting more than one vaccine)

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