Additional VFC Clinics
These clinics are for children 0-18 who are uninsured, underinsured, eligible for Badgercare/Medicaid, or Native American/Alaska Native.
Demographics
If you have multiple children receiving vaccines, a new form will need to be completed for each child.
Name of Person Receiving Vaccines
*
First Name
Last Name
Preferred Name/Pronouns
Date of Birth of Person Receiving Vaccine
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Eligibility/Vaccines Needed
State Supplied Vaccine Eligibility
*
Medicaid/Badgercare Eligible or Enrolled
No health insurance
Insured, but insurance doesn't cover vaccines
Native American or Alaska Native
Do you know which vaccines your child needs or which vaccines you want them to receive
*
I do not know what vaccines my child needs- please determine at their appointment
I know which vaccines my child needs/I want them to receive (please select below)
Additional Comments
Vaccine(s) Requested (Please note we do use combination vaccines when able, so your child may not receive this number of vaccines)
Tetanus, Diphtheria, Pertussis
Hib (Haemophilus influenzae type B)
Hepatitis A
Hepatitis B
HPV (human papilloma virus)
Influenza
MMR (measles, mumps, rubella)
Meningitis
Meningitis B
Pneumococcal
Polio
Rotavirus
Varicella
COVID-19
Appointments
Brown County Central Library- 515 Pine St.
*
Submit
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