Vaccination Appointment Form

Vaccination Appointment Form

Door County Public Health offers vaccines at the Public Health Office every Wednesday by appointment only. To schedule an appointment, please fill out the information below. If you need assistance with scheduling or have questions on eligibility, please call 920-746-2234 or email publichealth@co.door.wi.gov
Door County Public Health's vaccination clinic serves:

Children 18 years of age and younger needing routine vaccination who meet one or more of the vaccine eligibility criteria outlined below.

Adults 19 years of age and older: Specific criteria allows for some vaccines to be offered to this age group, see Additional Eligibility Criteria for Adults.

Flu and COVID-19 vaccine available depending on vaccine eligibility criteria outlined below.

Insurance card(s) must be presented at time of appointment.
Please select the age category for this appointment:

Child Ages 0-18Adult Ages 19+
Child Vaccine Eligibility - Please select all that apply*

Medicaid/BadgerCare+Native American or Alaskan NativeNo Health InsuranceSeasonal Flu and/or COVID-19 Vaccine (ages 6 months - 18 years)
Child Seasonal Vaccines*

Flu (ages 6 months - 18 years)COVID-19 (ages 12+)COVID-19 (ages 6 months - 11 years)
Child Flu Vaccine Coverage/Payment - Please select all that apply*

Medicaid/BadgerCare+No Health InsuranceNative American or Alaskan NativeCommercial Insurance (Common Ground or United Healthcare Only)Cash or Check $50
Child Vaccine Coverage/Payment - COVID-19 (ages 12+)*

Medicaid/BadgerCare+No Health InsuranceNative American or Alaskan NativeCommon Ground or United Healthcare Commercial InsuranceCash or Check $165
Child Vaccine Coverage/Payment - COVID-19 (ages 6 months - 11 years)*

Medicaid/BadgerCare+No Health InsuranceNative American or Alaskan Native
Adult Vaccine Eligibility*

No Health InsuranceInsured, Vaccines Not CoveredSeasonal Flu and/or COVID-19 Vaccines
Adult Flu/COVID Vaccine Coverage/Payment (19+) - Please select all that apply*

Medicaid/BadgerCare+Medicare Part B (without an advantage plan)Medicare Advantage—Humana or United Healthcare Only for WI*Commercial Plan—Common Ground and United Healthcare (inc. UMR) Only for WI*Cash or Check ($50 standard flu/$98 high dose flu/$165 COVID-19)Uninsured/Underinsured Adult (19+)
Medicare Part B Member ID #*
XXXX-XXX-XXXX
Insurance Carrier (Medicare Advantage)*
Insurance Carrier (Commercial Insurance)*
Member ID #*
Please select an appointment date and time.*
Contact Information
Person Receiving Vaccine(s)*

First NameLast Name
Parent/Guardian - A parent or legal guardian must be present for appointment or provide signed authorization form.*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Phone Number*
Area code required
Email - By providing your email, you consent to receive confirmation and reminders via email.
example@example.com
Child Vaccine(s) Requested*

Birth to 24 Months Recommended VaccinesSchool Required VaccinesCOVID-19DTaP (Diphtheria, Tetanus, Pertussis)Hepatitis AHepatitis BHib (Haemophilus Influenzae Type B)HPV (Human Papillomavirus)Influenza (Flu)Meningococcal B (MenB)Meningococcal ACWY (MenACWY)MMR (Measles, Mumps, Rubella)PneumococcalPolioRotavirusRSVTdap (Tetanus, Diphtheria, Pertussis)VaricellaPlease determine other vaccines needed/available
RSV Eligibility*

Under 8 months old and over 11 pounds8-19 months old at increased risk for severe RSV disease
Adult Vaccine(s) Requested*

COVID-19Hepatitis AHepatitis BMMR (Measels, Mumps, Rubella)Tdap (Tetanus, Diphtheria, Pertussis)VaricellaPlease determine other vaccines needed/available
Adult Vaccine(s) Requested*

COVID-19Influenza (Flu) Standard DoseInfluenza (Flu) High Dose (ages 65+ only)
Adult Vaccine(s) Requested*

COVID-19 - $165Influenza (Flu) Standard Dose - $50Influenza (Flu) High Dose (ages 65+ only) - $98
Adult Vaccine(s) Requested*

COVID-19Influenza (Flu) Standard Dose
Additional Notes:
Should be Empty:

Vaccination Appointment Form

Contact Information