April 5, 2022 (Trinity Lutheran Church

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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? 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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Which vaccine appointment are you scheduling an appointment for?* This field is required.We will have both Pfizer & Moderna at this clinic. If you are unsure which vaccine to get, please ask your doctor or stick with the same one you got last time.
Pfizer 1st Booster (3rd Dose) --> given >5 months after 2nd dose
Pfizer 2nd Booster (4th Dose) --> given >4 months after 3rd dose
Moderna 1st Booster (3rd Dose) --> given >5 months after 2nd dose
Moderna 2nd Booster (4th Dose) --> given >4 months after 3rd dose
Moderna 3rd Dose (IMMUNOCOMPROMISED (3rd Dose)) --> given >28 days after 2nd dose
Moderna 1st Booster (IMMUNOCOMPROMISED (4th Dose)) --> given >3 months after 3rd dose
Moderna 2nd Booster (IMMUNOCOMPROMISED (5th Dose)) --> given >4 months after 4th dose
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Select an appointment time for your COVID-19 Vaccine at Trinity Lutheran Church* This field is required.IF THE APPOINTMENT SLOTS ARE GRAYED OUT OR DATES ARE UNAVAILABLE, THESE APPOINTMENT TIMINGS ARE ALREADY FILLED. **IF YOU CANNOT MAKE YOUR APPOINTMENT ON A SPECIFIC DAY, THE APPOINTMENT IS VALID AT ANYTIME DURING THE WEEK OF YOUR APPOINTMENT; YOU DO NOT NEED TO EMAIL OR CALL TO RESCHEDULE/CANCEL HOWEVER WOULD NEED TO GO TO SKIPPACK PHARMACY**
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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)
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
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The Bahamas
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The Gambia
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Iraq
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Israel
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Japan
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Jordan
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Kiribati
North Korea
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Kuwait
Kyrgyzstan
Laos
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Lesotho
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Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
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Maldives
Mali
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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
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Samoa
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Saudi Arabia
Senegal
Serbia
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Solomon Islands
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South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
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Other
Country
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Phone Number* This field is required.Cell phone number preferred
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Email AddressIf you do not have an email address, you can just click NEXT.
I.e. jonathansmith@gmail.com
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Demographic InformationIf you prefer not to answer, click NEXT.
Please Select
Please Select
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Other Race
Race
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Hispanic or Latino
Not Hispanic or Latino
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Ethnicity
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COVID-19 Vaccine Screening Questions* This field is required.Once you read the questions below, click the box under YES or NO based on your answer, then click NEXT.
YesNo
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? Had you ever had a severe allergic reaction after receiving a COVID-19 vaccine? Have you ever had a severe allergic reaction after receiving another vaccine or injectable medication? Have you ever had a severe allergic reaction after receiving Polyethylene Glycol? Are you currently pregnant or breastfeeding? Do you have a bleeding disorder or are you taking a blood thinner? Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days? 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? Do you have a history of Guillain-Barré syndrome (GBS)? Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)? 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.
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? Had you ever had a severe allergic reaction after receiving a COVID-19 vaccine? Have you ever had a severe allergic reaction after receiving another vaccine or injectable medication? Have you ever had a severe allergic reaction after receiving Polyethylene Glycol? Are you currently pregnant or breastfeeding? Do you have a bleeding disorder or are you taking a blood thinner? Have you received monoclonal antibodies or convalescent plasma as part of a COVID-19 treatment in the past 90 days? 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? Do you have a history of Guillain-Barré syndrome (GBS)? Do you have a history of multisystem inflammatory syndrome (MIS-C or MIS-A)? 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.
YesNo
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Consent* This field is required.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. 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. 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, 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.
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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) AND Medicare Part D card. 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, upload your Medicare Part D card. If you have difficulty uploading it in which case, we will ask for this at check-in.**Having this completed will expedite registration.**
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Max. file size: 10.6MB
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RX INSURANCE CARD: 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. Click "Next" if you have difficulty uploading it in which case, we will ask for this at check-in.
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 RX card and if applicable, Medicare B Card, 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. No insurance, put the last four digits of your social security number in the last box. After filling it out, hit "Next."If the card doesn't have a respective number or letters leave that field blank.
RX BIN
RX PCN
RX Group
Member ID
If 65+ or disabled, Medicare B # from your Medicare B Card (red, white and blue card)
If no active RX insurance, last four digits of your social security number
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Please input the numbers/letters from your PRESCRIPTION insurance card 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. 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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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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NO INSURANCE: If you DO NOT have active insurance, please input the information below. If this does not apply to you, click "Next"
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Which arm would you 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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Interested in Receiving Up To 8 At-Home COVID19 Tests for $0?By selecting Yes, you authorize Skippack Pharmacy to run the tests through your insurance. Only if your insurance covers it, we will have them available for pick up when you come to get your vaccine. The masks are free through the government.
AT-HOME COVID TESTS ONLY - yes, for up to 8 free COVID Tests if my insurance covers it
3 N95 MASKS ONLY - yes, for the free N95 masks through the government
AT-HOME COVID TESTS & N95 MASKS - yes, for the COVID tests through my insurance and masks through the government
No, I am not interested.
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Signature of Person to Receive Vaccine* This field is required.
Clear
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Date Signed
Date
Month
Day
Year
Should be Empty: