2026 - Skippack Pharmacy Vaccine Appointment Registration

2026 - Skippack Pharmacy Vaccine Appointment Registration

Thank you for choosing Skippack Pharmacy for your family’s vaccination needs. Please complete one appointment form per person. Completing your information ahead of time allows our team to prepare for your visit and helps make your appointment as quick and easy as possible. Questions? Email us at clinic@skippackpharmacy.com.
About You
Have you received a Vaccine Through Skippack Pharmacy Before?
What brings you to Skippack Pharmacy?
Selecting Your Vaccine(s)

Not sure which vaccines may be right for you? Visit SkippackPharmacy.com/Immunizations or email clinic@skippackpharmacy.com and our team can help.
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 4 on one visit.
Bringing a Young Child for Vaccination? 💙

We love caring for children and have several team members who are especially experienced with pediatric vaccinations.

Please keep in mind that not every vaccinator on duty may be able to vaccinate very young children or children who may need additional time, reassurance, or support during their visit.

If your child is nervous about vaccines, has difficulty sitting still, or may need a little extra attention, we highly recommend visiting during one of the following times, when our pediatric-experienced vaccinators are typically available:

Monday, Wednesday & Friday: 10 AM–5 PM

Tuesday & Thursday: 10 AM–6 PM
with Dr. Mak also typically available any time on Tuesdays and on Thursdays after 2 PM for children who may need additional support. For special circumstances, please email clinic@skippackpharmacy.com before your visit*

Saturday: 11 AM–2 PM
Pediatric-experienced nurse vaccinator available.

Helping Your Child Stay Safe & Comfortable
If you think your child may move during the vaccination, we recommend having the parent or caregiver sit in the immunization chair with the child securely on their lap. A gentle but secure “comfort hold” — similar to a hug — can help your child feel supported while also keeping their arm still during the vaccination.

Our goal is to make your child’s vaccination experience as safe, comfortable, and positive as possible.

Want more tips before your visit?
TIPS FOR CHILDREN'S VACCINES FROM CHOP
Which KIDS 3-11 YEARS OLD 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.
Which BABIES Vaccine(s) are you Scheduling an Appointment for? You can select up to 2 on one visit.
Which VACCINE REQUIRED FOR SCHOOL [Between 3-18 years old] 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.**
Eligible VFC vaccines are provided at $0 for the vaccine itself. A $20 administration fee per vaccine applies to help cover staffing and supplies. By selecting the option below, I confirm that I have checked with my child’s school nurse, school staff, or healthcare provider to determine which vaccine(s) are needed. Please confirm the required vaccine(s) before scheduling, as requirements vary by age, grade, and vaccination history.
Baby/Toddler Parent Attestation: Vaccine recommendations for young children may depend on age and previous vaccination history. Please review current recommendations and discuss any questions or concerns with your child's pediatrician or healthcare provider before the appointment.
Vaccine Screening Questions [Select what best describes your health or choose "None of the statements apply"]
Scheduling A Date/Time For Your Appointment

If you’re scheduling appointments for a spouse, child, friend, or other family member, simply choose the available time slots that are closest together. We’ll be happy to see your family or group together when you arrive. There’s no need to call or email us to coordinate.
📍 Appointment Location
Immunization Center at Skippack Pharmacy
4118 W Skippack Pike, Schwenksville, PA 19473
Across from Wawa in Skippack (Skippack Village)

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

First/Last Appointments of Day: We take the last appointment 15 minutes before we close and the first appointment at the the 10AM time our clinic opens
Need Special Scheduling Assistance?

Special accommodations, needle phobia, uninsured patients, and vaccinations for children age 2 and under may require advance coordination before scheduling.

👉 Review Special Scheduling Information
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.
Babies/Toddlers Appointment: Please pick a day and time below. 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 Information
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex at Birth
Email of Patient (or caregiver filling this out)
A non-Comcast email is recommended, as Comcast may filter our appointment emails. If you reach the Thank You page after submitting, your registration was successfully received.
Phone Number
Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Coverage Information
What type of prescription coverage does the patient have?
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.***

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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, 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.***

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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. After filling it out, hit "Next." We may reach out to you via text or phone if additional information is required.
Complimentary Benefits for Supporting Local
Would you like Skippack Pharmacy to MAIL YOU free COVID-19 tests and/or Narcan?As part of our commitment to keeping our community safe, Skippack Pharmacy can mail COVID-19 tests and/or Narcan directly to your home at NO COST to you — whether you have insurance or not. If applicable, we’ll process the items through your insurance. You will not be charged. COVID-19 tests can help you stay prepared during respiratory illness season, while Narcan (naloxone) is a life-saving medication that can quickly reverse an opioid overdose. Even if you or your family don’t personally expect to need Narcan, having it available could help save the life of a friend, neighbor, loved one, or someone in your community. [Click the image below to learn more about narcan]
Your Vaccine Gives Back 💙
Every vaccine given through Skippack Pharmacy gives back. For every vaccine we administer, Skippack Pharmacy will donate $1 to a charitable cause — and we'd like you to help decide where it goes. Which cause would you like your vaccine to support?
CONSENT & AUTHORIZATION: By checking the box below, I am providing my consent electronically and agree that my electronic acknowledgment and signature are the legal equivalent of my handwritten signature. I confirm that I have reviewed the Vaccination Consent & Authorizations and have been provided access to the applicable Vaccine Information Statement(s) (VIS) and/or patient information for the vaccine(s) selected. I have had the opportunity to ask questions before vaccination and consent to the administration of the vaccine(s) selected for me, or for the individual for whom I am legally authorized to provide consent. If I am signing on behalf of another individual, including a minor, I attest that I have the legal authority to do so. Patients under 18 must have the consent of a parent or legal guardian unless otherwise permitted by applicable law.
Signature of Patient or Parent/Legal Guardian/Authorized Representative
Date Signed

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
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, medication or treatment.
Previously diagnosed with Multisystem Inflammatory Syndrome (MIS-A or MIS-C)
History of myocarditis or pericarditis
Are you 65+ or have a condition that puts you at high risk for severe outcomes from COVID-19 virus
None of the Statements Apply

How Did You Hear About Us?
What is your preferred site of administration for the vaccine(s) Although this questions is here, please let the vaccinator know where you prefer to receive the vaccine(s).
Should be Empty:

2026 - Skippack Pharmacy Vaccine Appointment Registration

About You

Selecting Your Vaccine(s)

Scheduling A Date/Time For Your Appointment

Patient Information

Coverage Information

Complimentary Benefits for Supporting Local

Your Vaccine Gives Back 💙