Meadowood Senior Living (9-26-2024) COVID19 Vaccine Clinic

Event Name: COVID-19 Vaccination Clinic

Location: Schulz Center (Meadowood Senior Living)

Date & Time: Thursday Sept 26, 2024 10:00AM-1:00PM

I am scheduling for myselfI am scheduling this appointment for a resident in Skilled NursingI am scheduling this appointment for a resident living in Independent LivingOther

**NEW 2024-25 COVID-19 Vaccine, I am indifferent as to which brand I get****NEW 2024-25 COVID-19, Spikevax (Moderna) Vaccine/Booster, 12+****NEW 2024-25 COVID-19, Comirnaty (Pfizer) Vaccine/Booster, 12+**

Appointment: Please pick an appointment time below.

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

MaleFemaleOther

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

Please answer "Yes" or "No" to the questions below concerning your Medical History. 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?

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)I have Medicaid insurance (i.e. Keystone First, Health Partners, etc.)I don't have prescription insurance, Medicare, Medicaid, or any commercial or government-funded health benefit plan.

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 UPLOAD: For anyone with a prescription RX insurance card, please click "Upload Image or File" and upload copies of those cards 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 and 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."

Left ArmRight Arm

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

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