12-1 (Trinity Lutheran Church) Family Vaccine Clinic

Date: Friday Dec 1, 2023 (4P-7P)

Clinic Location: Trinity Lutheran Church (1000 W Main Street, Lansdale, PA 19446)

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Uninsured or Underinsured? We have your back!

Skippack Pharmacy is enrolled with the federal Bridge program, state VFC (vaccines for children) program, and collaborating with the Montgomery County Health Department to ensure irrespective of your insurance status, you can receive the flu/COVID-19 vaccine at no cost to you.

If you are 19+ uninsured or underinsured & looking for a COVID-19 vaccine...please click this link: www.tinyurl.com/uninsuredCOVID to sign up for a free COVID-19 voucher (do this before proceeding below as we will need information from the voucher entered during this registration). If you are under 18 uninsured or underinsured & looking for a COVID-19 vaccine: you do not have to fill out additional for the Bridge program. Please proceed below.

If you are uninsured or underinsured & looking for a FLU vaccine...you can proceed below (do not need to sign up for any voucher).

What brings you to this Vaccine Clinic hosted by Skippack Pharmacy?

Age of Person To Receive Vaccine

How old is the patient who you are scheduling an appointment for? DO NOT USE DECIMALS. If patient is 5.5 years, old put 5. 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. For COVID-19 vaccines, if you are indifferent to which brand you get, select the option which says "I AM OKAY WITH WHICHEVER IS AVAILABLE"

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

Have you received a Vaccine Through Skippack Pharmacy Before?

Patient Name

First NameLast Name

Patient Date of Birth

Date

Gender at Birth

Email of Patient (or caregiver filling this out)

example@example.com

Phone Number

Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Demographic Information (Optional)

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 anwer "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
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?
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?

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 & thus we bill your insurance.

BRIDGE - I am over 19 & do not have prescription insurance, Medicare, Medicaid, or any commercial or government-funded health benefit plan. I have signed up for the Bridge Program (www.tinyurl.com/uninsuredCOVID) and have a voucher in which I will enter the information from that voucher below. Without that voucher information entered in the next steps, we will not be able to process the vaccine for you.

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. If you do not have insurance, put in the last 4 of your SSN. After filling it out, hit "Next." Not providing this informaton now could delay your registration on-site.

Would you like at-home COVID-19 tests IF your insurance covers it at NO COST TO YOU? [if your insurance does not cover tests, you will not be charged/you will not receive tests]

Which arm would you like to receive your vaccine(s) in?

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

Superheroes Family Vaccine Tour: 12/1/2023 (Trinity Lutheran Church)