2700 S 60th St, Milwaukee, WI 53219
P: 414-988-0008
F:414-375-6880
Flu and RSV vaccine is now available
NEW COVID Pediatric vaccine available now at the pharmacy
*Parents, if your child is under 6 years old, you must have your pediatrician send a prescription BEFORE your appointment.
For information about the vaccine click on the image
Section I. Personal Information
Please Remember that if your child is under 6 years old, you must have your pediatrician send a prescription BEFORE your appointment.
Section III. Appointment Scheduler
Section IV. Signatures
I understand the benefits and risks of the COVID-19 vaccine as described in the Emergency Use Authorization (EUA) (Pfizer Fact Sheet) (Pfizer 5-11 Fact Sheet) (J&J fact sheet) (Moderna fact sheet), 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.
By signing this form, I acknowledge that I/ the person named above are phase eligible according to CDC guidelines.
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.
* For Medicare cardholders, please bring this card with you.
* For all other insurances, please bring your prescription card with you. It should have "RxBIN, RxPCN, RxGRP"
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.