PV - KIDS SECOND DOSE VACCINE CLINIC (11-29-2021)

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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?* 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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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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Before you schedule your appointment* This field is required.Authorized for patients age 5+: Pfizer two-dose vaccine Pfizer 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.
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Which Pfizer vaccine appointment are you scheduling an appointment for?* This field is required.https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/children-teens.html
2nd Dose Pfizer (5-11 year old) - First dose was received on or before November 8, 2021.
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Select an appointment time for your COVID-19 Vaccine at SKIPPACK ELEMENTARY* This field is required.****IF THE APPOINTMENT SLOTS ARE GRAYED OUT OR DATES, THESE APPOINTMENT TIMINGS ARE ALREADY FILLED. THIS APPOINTMENT IS ONLY VALID ON THE DATE OF THE CLINIC - IF YOU CANNOT MAKE YOUR SCHEDULED TIME, YOU MAY COME AT THE EARLIEST YOU CAN ON THE SAME DAY; THEREAFTER, YOU WILL NEED TO SCHEDULE A NEW APPOINTMENT ON WWW.SKIPPACKPHARMACY.COM**
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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) **5-11 Year Old ONLY For This Clinic**
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.
Drag and drop files here
Select files to upload
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 Address* This field is required.Enter an email address you check often. In case you don't receive communication from us be sure to check your spam.
I.e. jonathansmith@gmail.com
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Vaccine Recipient's Race* This field is required.
Please Select
Please Select
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Other Race
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Vaccine Recipient's Ethnicity* This field is required.
Please Select
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
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Emergency Contact Name + Phone Number* This field is required.
I.e. John Smith - 294-299-2945
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For vaccine recipients, you are now going to answer a series of questions.

The following questions will help us determine if there is any reason you should not get the COVID-19 vaccine. If you answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means you may need to consult with your doctor or healthcare provider prior to receiving your vaccine. Healthcare professionals or staff of the Skippack Pharmacy COVID-19 Vaccine Clinic will not provide any medical guidance on if you should or should not be receiving the vaccine. This is at the discretion of the vaccine recipient and their health care provider. If you are unsure about something, we suggest you call your doctor prior to coming to the clinic.

By clicking next, you acknowledge the above.
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COVID-19 Vaccine Screening Questions* This field is required.Additional Information:https://www.cdc.gov/vaccines/covid-19/downloads/pre-vaccination-screening-form.pdf
Yes
No
1. 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?
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2. Had you ever had a severe allergic reaction after receiving a COVID-19 vaccine?
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3. Have you ever had a severe allergic reaction after receiving another vaccine or injectable medication?
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4. Have you ever had a severe allergic reaction after receiving Polyethylene Glycol?
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5. Have you ever had a severe allergic reaction related to receiving Polysorbate or products containing Polysorbate?
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6. Are you currently pregnant or breastfeeding?
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7. Do you have a bleeding disorder or are you taking a blood thinner?
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8. Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days?
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9. 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?
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10. Do you have a history of Guillain-Barré syndrome (GBS)?
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11. Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)?
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12. 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.
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1. 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?
2. Had you ever had a severe allergic reaction after receiving a COVID-19 vaccine?
3. Have you ever had a severe allergic reaction after receiving another vaccine or injectable medication?
4. Have you ever had a severe allergic reaction after receiving Polyethylene Glycol?
5. Have you ever had a severe allergic reaction related to receiving Polysorbate or products containing Polysorbate?
6. Are you currently pregnant or breastfeeding?
7. Do you have a bleeding disorder or are you taking a blood thinner?
8. Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days?
9. 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?
10. Do you have a history of Guillain-Barré syndrome (GBS)?
11. Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)?
12. 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.
Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Yes
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No
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Consent (check each box below after reading and prior to signing the form)* This field is required.
I acknowledge & consent the above.
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.
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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. 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.
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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).
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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.
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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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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. 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 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.
I acknowledge & consent the above.
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I acknowledge & consent the above.
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I acknowledge & consent the above.
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I acknowledge & consent the above.
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I acknowledge & consent the above.
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Vaccine Recipient's 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). Your Medicare Advantage or Part D plan is not required but also may be uploaded. If you are not enrolled in Medicare and have non-Medicare insurance, please provide your commercial insurance coverage (RX & Medical).
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 or have difficulty uploading it.**Having this completed will expedite registration.**
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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If on Medicare, Please enter Medicare Number on Medicare B card and click "Next". If this does not pertain to you, click "Next"I.e. 1EG4-TE5-MK72
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INSURANCE CARD: For anyone with a prescription RX/medical insurance card, please click "Upload Image or File" and upload copies of those cards herein and then click "Next." Click "Next" if you do not have an insurance card or have difficulty uploading it.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Please input the numbers/letters from your insurance card below. After filling it out, hit "Next." If you do not have active insurance, leave blank and hit "Next"If the card doesn't have a respective number or letters leave that field blank.
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NO INSURANCE: If you DO NOT have active insurance, please input the information below. Your info will help us properly bill the Health Resources & Services Administration. Either way, there'll be no cost to you. If this does not apply to you, click "Next"
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Which arm would the vaccine recipient like to receive the vaccine?Please inform the staff member or volunteer at check-in & the vaccinator which option you select.
Left
Right
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Signature of Parent/Guardian* This field is required.
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Date Signed
Date
Month
Day
Year
Should be Empty: