Complete all required fields on this form to schedule an appointment for your first COVID vaccine dose. If you have remaining questions, please call us at (414) 999-1099.
Section I. Personal Information
Section II. Health Insurance
This next section regards health insurance. The vaccine is free of charge to all people living in the United States, regardless of their immigration or health insurance status.
Section III. Questionnaire for Immunization
Section IV. Appointment Scheduler
**Vaccine supply is limited. Please keep your appointment or call if you need to cancel or change it. **
Section IV. Signatures
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA), a copy of which I was provided with this Consent and Release. I have had a chance to ask questions that were answered to my satisfaction. I request the vaccine to be given to me or to the person named above, a minor for whom I represent that I am authorized to sign this Consent and Release.
For individuals between the ages of 12 -17:
I understand the benefits and risks of the vaccine and ask that the vaccine be given to the child listed above for whom I am authorized to make this request. I GIVE CONSENT to Health Connections, Inc. and its staff for my child named at the top of this form to be vaccinated with this vaccine. By signing this consent, I GIVE CONSENT that my child will receive the first and second part of the vaccine series without the parent/gaurdian present.
Pfizer COVID-19 vaccine (both doses in a 2-dose series, separated by 3 weeks)
I have received a copy of the notice of Privacy Practices. I understand the notice of Privacy Practices provides an explanation of the ways in which my health information may be used or disclosed by the pharmacy and of my rights with respect to my health information. I have been provided with the opportunity to discuss concerns I may have regarding the privacy of my health information.
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.