2025 - Skippack Pharmacy Vaccine Appointment Registration

2025 - Skippack Pharmacy Vaccine Appointment Registration

Thank you for choosing Skippack Pharmacy for your family's vaccination needs. We look forward to the opportunity to serve you & want to help you spend less time in person, so let's take care of intake details for you now! This one universal vaccine registration form is used for all age groups & all vaccines so if you are coming together as a family or setting up multiple appointments, you will need to fill out 1 appointment form per person. Any questions, please reach out to us at clinic@skippackpharmacy.com. ***If you, your child or other individual needing vaccination has a special need or arrangement (disability, needle fear/anxiety, car-bound, etc.), please email clinic@skippackpharmacy.com to schedule a time when one of our special vaccinators is available - for any special circumstance, if your appointment is not pre-arranged & confirmed with a team member via email, our in-store team may not be able to assist you on the day of***
Clinic Location: Immunization Center at Skippack Pharmacy

(4118 W Skippack Pike, Skippack, PA 19474), across Wawa Skippack
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?*

I NEED AN ADULT VACCINE (12+) --> I need to sign up for a vaccine for myself or family memberI NEED A KIDS VACCINE (3-11 years old) --> I need to sign up for a vaccine for my childBABIES/TODDLER VACCINE (6mo-2 years old) --> I need a COVID or FLU vaccine for my baby/toddlerVACCINE NEEDED FOR SCHOOL (VFC) --> I need a non-COVID, non-FLU vaccine for my child that is required for school and my child is uninsured, underinsured, or has Medicaid (between 5 years and 18 years old)
Have you received a Vaccine Through Skippack Pharmacy Before?*

Yes, the patient is 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 the last vaccineYes, the patient is in Skippack Pharmacy's system BUT there has been CHANGE in information (i.e. phone number, email address, RX insurance information, etc)No, this will be the patient's first vaccine through Skippack Pharmacy!Not sure, not sure if the patient has received a vaccine through Skippack Pharmacy before.
How Did You Hear About Us?*

I Am A Patient of Skippack PharmacyMy DoctorMy Child's PediatricianA Friend / Family MemberNewsSkippack Pharmacy WebsiteGoogleInstagramFacebookPharmacy Text MessagePharmacy EmailOther
Which Vaccine(s) Should I Get To Stay Protected?

COVID-19 (Pfizer or Moderna, 12+) – 65+ or under 64 with increased risk of COVID-19

Flu (Flucelvax, ages 12–64) – Annual flu shot for everyone 6 months and older.

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

Tdap (Boostrix, 18+) – One dose if you’ve never had Tdap, then a booster every 10 years

RSV (Mrsevia, 60+ or high-risk 50+) – One dose for older adults or those at higher risk.

RSV (Abrysvo, Pregnancy) – Given during pregnancy (32-36 wks gestational) to protect newborns.

Shingles (Shingrix, 50+) – Two doses, with the 2nd dose 2–6 months after the 1st.

Pneumonia (Capvaxive-21) – One dose for those 50+ or 19-49 with health conditions

Hepatitis B (Engerix-B, 18+) – All adults 18+. One round of three-dose series at 0, 1, and 6 months.

Hepatitis A & B (Twinrix, 18+) – Combination series for adults needing protection against both A & B.

MMR (Measles, Mumps, Rubella, 18+) – Two doses if not previously vaccinated or immune.

You may safely get up to 3 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 ADULT 12+ Vaccine(s) are You Scheduling an Appointment for? Select any which you would like to receive on this visit. You can select up to 3 on one visit.*

COVID-19 12+ (Pfizer or Moderna), I'll let the pharmacist choose for me, 2025-26COVID-19 12+ (Moderna only), 2025-26COVID-19 12+ (Pfizer only), 2025-26SENIOR FLU Vaccine (65+) - FLUAD, 2025-26FLU Vaccine (12-64) - FLUCELVAX, 2025-26TDAP: BOOSTRIX: 18+RSV (Respiratory Synctial Virus): 60+ OR 18-59 with increased health risksRSV (Respiratory Synctial Virus): PREGNANT ONLY -- ABRYSVOSHINGLES: SHINGRIX, 1st Dose, 50+SHINGLES: SHINGRIX, 2nd Dose, 50+, 2-6 months after 1st dosePNEUMONIA: PREVNAR 20 or CAPVAXIVE 21, whichever is available, 50+PNEUMONIA: CAPVAXIVE 21 only, 50+PNEUMONIA: PREVNAR 20 only, 50+HEPATITIS B: ENGERIX B, 1st Dose, 18+HEPATITIS B: ENGERIX B, 2nd Dose (1 month after 1st dose)HEPATITIS B: ENGERIX B, 3rd Dose (6 months after 2nd dose)HEPATITIS A & B: TWINRIX, 18+MMR (Measles): 18+***COMING SOON----NOT AVAILABLE YET----DO NOT SELECT YET: COVID-19 12+ (Novavax only), 2025-26***COMING SOON----NOT AVAILABLE YET----DO NOT SELECT YET: Flumist Nasal Spray, 2025-26
Which KIDS Vaccine(s) are You Scheduling an Appointment for? Select any which you would like to receive on this visit. *If you know your child will need extra attention &/or is very afraid of needles, please email clinic@skippackpharmacy.com & we will help you schedule a vaccine for when a special vaccinator is scheduled**

COVID-19 - KIDS 3-11 (Moderna only), 2025-26Flu Vaccine, 2025-26***COMING SOON----DO NOT SELECT YET: COVID-19 - KIDS 5-11 (Pfizer only), 2025-26
What Dose Number is this for Your Baby/Toddler?*

Unvaccinated - Dose 1 MODERNAUnvaccinated - Dose 2 MODERNAVaccinated - 2024-2025 Booster MODERNA DoseFlu Vaccine (6 months-2 years old), 2025-26
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.*

By checking this box, I agree with the statement above.I do not agree with the above (you will not be able to move forward with scheduling an appointment). I will contact my baby's pediatrician and then schedule an appointment.
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.***

DTaP (DAPTACEL: Diptheria, Tetanus, and Pertussis) - <6 yrs***Td (TENIVAC): Tetanus and Diptheria - 7+ yrs***TDap (ADACEL: Tetanus, Diptheria, Pertussis) - 7+***MMR: Measels, Mumps, Rubella - >1 yr***Hepatitis B (ENGERIX: Hepatitis B) - Any Age***MCV4 (MENQUADFI: Meningitis) - 2+ yrs***DTaP-IPV-HepB (PEDIARIX: Diptheria, Tetanus, Pertussis, Polio, Hepatitis B) - <6 yrs***POLIO: Poliovirus - 1-19 yr***Flu (FLUCELVAX) - >6mo+HepA (HAVRIX: Hepatitis A) - <18 yrsPEDVAXHIB (Haemophilus influenzae type b Vaccine) - <6 yrsGARDISAL (HPV 9 Vaccine) - >9 yrsROTARIX (Rotavirus Oral Vaccine) - <6 mosPneumococcal 15-Valent Conjugate VaccineVARICELLA (CHICKENPOX)-<19 yrs
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.*

By checking this box, I agree with the statement above.I do not agree with the above (you will not be able to move forward with scheduling an appointment). I will contact my school and then schedule an appointment.
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.
Appointment: Please pick a day and time below (to see next month's appointments, click on the down arrow next to the current month) *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**
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*

MonthDayYear
Date
Gender at Birth*

MaleFemaleOther
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*
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 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.*

	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. 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. **Our team will try to pull your insurance information based on what is provided / in our system; however, in some cases may reach out to you for a copy of your card or ask for that in person***

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 prescription insurance & would like to receive a flu vaccine.I do not have prescription insurance & would like to receive a COVID-19 vaccine (Moderna 12+ only).I do not have prescription insurance & will pay out of pocket for the cost of the vaccine.Vaccine For Children - I am under 18 & do not have prescription insurance, Medicare, Medicaid, or any commercial or government-funded health benefit plan. I will pay $20 per vaccine for the administration fee.
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.***

Cancelof
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.***

Cancelof
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]*

YES - please mail me a care kit that includes COVID-19 tests & NarcanYES - please mail me NarcanNO - I am not interested in either COVID tests or Narcan.
What is your preferred site of administration for the vaccine(s)?*

Left Arm (1 vaccine)Right Arm (1 vaccine)Vaccines in Both Arms (if you selected 2 or 3 vaccines on one visit)Vaccines in Left Arm Only (if you selected 2 or 3 vaccines on one visit)Vaccines in Right Arm Only (if you selected 2 or 3 vaccines on one visit)
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*

Clear
Date Signed
Should be Empty: