BFP COVID Vaccine List

Ballweg Family Pharmacy COVID Vaccination Request Form

Ballweg Family Pharmacy Vaccination Request Form. Please note that completing this form does not guarantee that you will receive vaccine. The team from Ballweg Family Pharmacy will contact you via email or phone to notify you when you are eligible to book your vaccine appointment as the vaccine becomes available. If you are filling this form out for additional family members over 18 years of age, please fill out ONE FORM PER PERSON. The vaccines will be provided at no cost to the patient.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Age: *
Email: *
example@example.com
Phone Number *

Area Code Phone Number
Can we text the phone # above? *

Yes No
Are you currently a patient at Ballweg Family Pharmacy? *

Yes No
What is your vaccine interest? *

I am an individual, looking to obtain the vaccine for myself and/or my family. (Individuals under 18 will need consent from an adult) I am an owner/manager/admin, looking to obtain the vaccine for my staff/school/workplace/institution (if so, please include name of location/site in "additional information" below) I represent a Long-Term Care Facility or Nursing Home looking to obtain vaccine for my residents/staff (if so, please include facility in "additional information" below) I represent a group home situation and am looking to obtain vaccine for my residents.
Please provide additional information or context that you feel might be relevant including appointment availability:
Because the supply of COVID-19 vaccine in the United States is expected to be limited at first, the CDC is providing recommendations to federal, state, and local governments about who should be vaccinated first. CDC’s recommendations are based on recommendations from the Advisory Committee on Immunization Practices (ACIP), an independent panel of medical and public health experts. The recommendations were made with these goals in mind: *Decrease death and serious disease as much as possible. *Preserve functioning of society. *Reduce the extra burden COVID-19 is having on people already facing disparities. * * Center Pharmacy will follow the Wisconsin COVID-19 Vaccination Phase guidance: https://www.dhs.wisconsin.gov/covid-19/vaccine-about.htm
Acknowledge above *

Yes
Please choose the CDC Vaccination Phase that best describes your situation or condition: *

Phase 1-A: Long-term care facility residents. Phase 1-A: Health care personnel including, but not limited to: Emergency medical service personnel (EMT, EMS), Nurses, Nursing assistants, Physicians, Dentists, Dental hygienists, Chiropractors, Therapists, Phlebotomists, Pharmacists, Technicians, Pharmacy Technicians, Health professions students and trainees, Direct support professionals, Clinical personnel in school settings or correctional facilities, Contractual HCP not directly employed by the health care facility Phase 1-A: Persons not directly involved in patient care but potentially exposed to infectious material that can transmit disease among or from health care personnel and patients Phase 1-B: People ages 75 and older Phase 1-B: People in congregate settings not otherwise specified as LTCF and persons receiving home and community-based services Phase 1-B: First responders, Correctional officers and other workers serving people in congregate care settings not included in Phase 1A, Food and agricultural workers, U.S. Postal Service workers, Manufacturing workers, Grocery store workers, Education workers, Clergy and other essential support for houses of worship, Public transit workers, Individuals caring for children or adults in early childhood and adult day programs Phase 1-C: People ages 65-74 Phase 1-C: People aged 18-64 with high risk conditions causing increased risk for severe disease Phase 1-C: Essential workers in these sectors: Transportation and logistics, Water and wastewater, Food service, Housing construction, Finance, including bank tellers, Information technology, Communications, Energy, including nuclear reactors, Legal services, Federal, state, county and local government workers, including county election workers, elected officials and members of the judiciary and their staff, Media, Public safety, Public health workers Phase 2: All individuals not previously covered who are 18 and older and do not have a contraindication to the vaccine
**This phasing is an interim vaccine plan from the department. Many components of the COVID-19 vaccine plan remain fluid and continue to be modified and adapted as more announcements and decisions are made at the federal level. The department is continuing to receive feedback and will be modifying this plan and posting public updates to this in the coming weeks.** *
DISCLAIMER: please note that your submission of a response to this survey does not guarantee that you will receive a vaccine. We are following the strict CDC and WI DHS guidelines on prioritization of vaccination. We kindly ask that you do not contact the pharmacy for an update on when you will be getting your vaccine. We assure you that you will be contacted AS SOON AS you are eligible for the vaccine - and we have vaccine in stock. THANK YOU for your patience and understanding! *
*

I acknowledge above
DATA: Data from this form will not be shared however, I acknowledge & give consent to Center Pharmacy to communicate with me via phone or email. *

Acknowledge
Should be Empty:

Ballweg Family Pharmacy COVID Vaccination Request Form