Attention All Patients
The pharmacy may only administer vaccinations to patients that are 6 years old and qualify via CDC defined criteria. Not all qualifications are listed below and this does not guarantee the pharmacy may administer a vaccine. Please call before coming if you wish to verify your qualification.
The pharmacist will need to verify if getting the pneumonia vaccine is recommended for you at this time. Please wait for the pharmacy to contact you before coming in for your vaccination. If you do not hear from the pharmacy before your appointment please call us at 715-743-3500 to verify whether or not you should come in. Please complete the form at this time.
For Patients: The following questions will help us determine which vaccines you may be given today. If you answer "Yes" to any question it does not necessarily mean you should not be vaccinated today. It just means additional questions maybe asked. If a question is not clear, please ask us to explain it.
Form reviewed by (Pharmacist):______________________________________________Date:__________
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