Vaccine Appointment Form

Vaccine Appointment Form
COVID 19 Vaccine Appointment *
COVID-19 Vaccine Appointment*
Please check ALL of the reasons why you may have hesitated or delayed in getting a COVID-19 vaccine before today.*

I did not have transportation/a way to actually get a vaccine site (no ride)I did not have time to get to a vaccine site because I had to work at my job(s)I did not have time to get to a vaccine site because of my child care or other family commitments (busy with kids or family)Information that I learned about the vaccine scared me - but I later learned that this was wrong informationI was concerned about the vaccine's potential side effectsI was not worried about getting COVID-19 (the virus/illness) and therefore I didn't think I really needed the vaccineI don't really trust doctors and/or the health care systemI don't really trust vaccines in general and I don't usually get any vaccinesThis (COVID-19) vaccine in particular scares me, although I've gotten other types of vaccines before (like tetanus or flu shots)I did not know where or how to get the vaccineI did not know that the vaccine would be free (at no cost to me)I really don't know why I was hesitant to get the vaccine beforeNone- I don't have any concerns making me hesitate to get a COVID-19 vaccineOther
If you are getting the COVID-19 vaccine booster shot today as a result of someone reaching out to you with information, please tell us what sources of information you received that made the difference and helped you decide to get vaccinated.*

I saw a community website, blog, or web-based tool about COVID-19 vaccinesA social media site (or related campaign) about COVID-19 vaccinesSomeone came to my home for door-to-door outreachSomeone came to my housing or apartment complex to give informationSome other health worker provided me informationI received a telephone call (or calls)I received text message(s)I received email(s)I received mailI joined a webinarI joined a training sessionI joined a virtual town hallI heard a radio spotI saw a TV spotI saw billboards or other types of posters/signs around my community\Someone left information hanging on my door knobI received a flyerI was in a focus groupI attended and got information at a community fair or eventI was at and got information from a community-based recreation centerI was at and got information from a church, temple, or other religious siteI was at and got information from a local school, college, or a community learning centerI was at and got information from a local library or other public buildingI was at and got information from an LGBTQ+ community/resource centerI was at and got information from a community/resource center for a population of people sharing a common background with me (Italian Americans club, a meeting place for Spanish-speakers, etc.)I was at and got information from a facility helping unhoused people (homeless shelter, etc.)A friend, family member, or neighbor suggested that I get the booster vaccineI didn't get information from any of the things listed hereOther
Do you need a ride to your appointment?*

YesNo
Our pharmacy offers free rides through Uber Health. Are you interested in setting up a ride to your appointment?*

YesI am interested, but would like to learn moreNo
St. Vincent de Paul Charitable Pharmacy has teamed up with Sosento and Uber Health to provide free patient rides to the clinic to access medical services as well as COVID vaccines and educational info! We are excited for this opportunity to better serve our patients!
Name*

First NameLast Name
Date of Birth (REMINDER: SVDP DOES NOT OFFER COVID-19 VACCINES TO CHILDREN UNDER THE AGE OF 12 AT THIS TIME!)*

MonthDayYear
If you are looking to have a child under 12 vaccinated, please call or visit Fitchburg Family Pharmacy directly off of Fish Hatchery by the Pick N' Save (3050 Cahill Main, (608) 274-3784). If you have GHC insurance, you can also check out GHC Clinic next door to Fitchburg Family Pharmacy. If you have any questions regarding vaccines for children under 12, feel free to give our pharmacy a call.
Cell Phone Number*
Please enter a valid phone number.
Primary Phone Number*
If same as Cell Phone Number, please re-enter
Primary Phone Type*

CellHomeWork
Email
example@example.com
Address Line 1*
2021 Vaccine Ln
Address Line 2
Apt. 210A
City*
State*

WIOther
Zip Code*
County*

DaneOther
Race*

Black or African AmericanAmerican Indian or Alaskan NativeAsianWhiteNative Hawaiian or Other Pacific IslanderI prefer not to sayOther
Ethnicity*

Hispanic/LatinoNot Hispanic/LatinoUnknownUnable to report due to policy/law
Please select ALL of the following that you identify as:*

MaleFemaleTransgenderGenderqueer, gender nonconforming, or nonbinaryAgenderI prefer not to answerOther
Please select ALL of the following that you identify as:

Straight or heterosexualLesbian or gayBisexualQueer or pansexualQuestioningDon't knowI prefer not to answerOther
First/Main Language*

EnglishSpanishHmongOther
Mother's Maiden Name*
If unknown, please put Mother's Last Name
Guardian*
Name of Parent/Guardian
Employer
Do you have health insurance?*

YesNo
Member ID Number*
Member ID # could be anywhere from 5-12 digits long, and is sometimes listed under different names, such as "Member ID", "ID Number", or "Membership ID". If you CANNOT FIND or DO NOT KNOW your Member ID #, please call your insurance provider.
Rx Group*
Rx Group #'s can be alphanumeric or numeric. It can be listed as "RxGrp" or "Prescription Group" as well. IF you CANNOT FIND or DO NOT KNOW your Rx Group #, please call your insurance provider.
Rx BIN*
Rx BIN is a 6 digit number. IF you CANNOT FIND or DO NOT KNOW your Rx BIN Number, please call your insurance provider.
Rx PCN
PCN's can be alphanumeric or numeric. NOT ALL health insurance plans use PCN's, so it's okay to leave this blank if you don't see it on your health insurance card. IF you are UNSURE IF your insurance plan has a PCN, please call your insurance provider.
Do you have any additional questions or comments for us?
We are a non-profit pharmacy funded largely by donations. Would you be interested in donating to St. Vincent de Paul in the future?*

YesNo
SVDP Donation Site

https://svdpmadison.org/donate/
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