COVID-19 Vaccine Appointment Cancellation

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for informing our team that you would like to cancel your COVID-19 vaccine appointment. As we continue to fight COVID-19 as a community, you informing us of this, will allow us to ensure vaccines are not wasted in the process of no-shows.

What is your UNIQUE ID number in your confirmation?

Leave blank if you are not sure.

What is your first & last name?

What date was your appointment time?

YYYY

What is the reason for cancellation?

I or a family member contracted COVID or am not feeling well.

Something came up and I can no longer make it.

I received my vaccine elsewhere.

I no longer want to receive the vaccine.

The date/time does not work for me anymore & I'd like to reschedule it (you can reschedule online at www.SkippackPharmacy.com/COVID19)

Other:

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Skippack Pharmacy.

Does this form look suspicious? Report

Forms