Ballweg Pharmacy COVID Vaccine Wait List

Ballweg Family Pharmacy COVID Vaccination Request Form
- Filling out this form does not guarantee that you will recieve the vaccine.
- Fill out one form for EACH PERSON that you would like to add to the list
- Provide as much detail as you can about your employement or health if you expect that to be your qualifying reason for early distrubtion of the vaccine.
- You can see current state of Wisconsin guidelines here: https://www.dhs.wisconsin.gov/covid-19/vaccine-about.htm
- You may add yourself to the wait list before you qualify and we will reach out to you as the phasing opens up.
- Vaccine distrubution to our pharmacy is calculated on our local population right now. We will only be vaccinating those that can prove residence within 15 miles of our pharmacy until vaccine is much more readily available.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Age: *
Email *
example@example.com
What zip code do you live in? *

53578 53583
Phone Number (Mobile preferred for text messaging) *

Area Code Phone Number
Do you currently fill prescriptions at Ballweg Family pharmacy? *

Yes No
Ballweg Pharmacy will follow the Wisconsin COVID-19 Vaccination Phase guidance: https://www.dhs.wisconsin.gov/covid-19/vaccine-about.htm We will contact you via email AND phone once we have reached you on our list. Please be patient, we have been getting sporadic and smaller delieveries so far in this process.
Acknowledge above *

Yes
Please choose all that apply to you: *

Frontline Healthcare Personnel Residents or staff in skilled nursing and long-term care facilities. Police, Fire personnel, or correctional staff Adult ages 65 and older Individual with any of the following health conditions: Asthma, cancer, cerebrovascular disease, chronic kidney disease, COPD, cystic fibrosis, down syndrome, heart condition, high blood pressure, immunocompromised, liver disease, dementia, BMI greater than 25, pregnant, pulmonary fibrosis, severe obesity, sickle cell disease, diabetes, or thalassemia Educator or childcare providers: Definition:*All staff in regulated child care, public and private school programs, out-of-school time programs, virtual learning support, and community learning center programs. *All staff in Boys and Girls Clubs and YMCAs.All staff in preschool and Head Start through K-12 education settings. *Faculty and staff in higher education settings who have direct student contact. Individual enrolled in one of the listed Medicaid long term care program:*Family Care and Family Care Partnership *Participants in IRIS (Include, Respect, I Self-Direct)*Children ages 16 years and older in the following programs: Children’s Long-Term Support Waiver Program*Katie Beckett Program*Children’s Community Options Program (CCOP)*Children Come First*Wrap Around Milwaukee*Children with Medical Complexity Program Public facing essential worker in the following fields: 911 operators *Utility and communications infrastructure workers who cannot socially distance, *Public transit drivers who have frequent close contact with members of the public*Food supply chain: agricultural production workers, such as farm owners and other farm employees.*Critical workers who provide on-site support to multiple agricultural operations, such as livestock breeding and insemination providers, farm labor contractors, crop support providers, and livestock veterinarians.*Food production workers.*Retail food workers, such as employees at grocery stores, convenience stores, and gas stations that also sell groceries.*Hunger relief personnel, including people involved in charitable food distribution, community food and housing providers, social services employees who are involved in food distribution, and emergency relief workers. Non-frontline health care personnel Live or work in employer-based housing, housing serving the elderly or people with disabilities, shelters, transitional housing, or incarcerated individuals. Healthy person under the age of 65 that does not work as an essential worker as defined above.
IF YOU PICKED PHASE ONE ABOVE AND ARE UNDER 65, PLEASE INDICATE YOUR JOB OR HEALTH CONDITION THAT QUALIFIES YOU:
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. These phasing plans are fluid and we are adapting as the plans change. 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 BALLWEG FAMILY PHARMACY TO COMMUNICATE WITH ME VIA PHONE OR EMAIL.
*

I acknowledge above
Do you attest that information that you have provided above is truthful and correct? If so, please type your name here: *

First Name Last Name
Should be Empty:

Ballweg Family Pharmacy COVID Vaccination Request Form