Online Vaccine Check In

Brookfield Vaccine Center

Vaccine Check-in
Please Select Patient Age*

3-11 Years12+ Years

Child's Full Name*

First NameLast Name

Child's Birth Date *
mm/dd/yyyy
Sex*

MaleFemale

Primary Phone*
Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

City

Zip Code

Is the child feeling sick today?*

YesNo

Has the child ever had an allergic reaction (e.g., anaphylaxis) to any medications, vaccines, or foods? (e.g., eggs, latex, polyethylene glycol, polysorbate)*

YesNo
Please specify *

Has the child ever had a serious reaction after a vaccination for which they had be treated with epinephrine or for which they had to go to the hospital?*

YesNo
Please specify *

Has the child received any vaccines in the past 28 days?*

YesNo
Please specify *

Does the child have any long-term health condition(s)? For example: heart disease, lung disease, liver disease, diabetes, kidney disease, bleeding disorder)*

YesNo
Please specify *

Does the child or member of the household have an immunocompromising condition? (e.g., being treated for cancer, HIV/AIDS, or other immune system problems or taking medication that may weaken the immune system such as prednisone or injectable biologic)*

YesNo
Please specify*

In the past 3 months has the child taken a medication that affects the immune system such as steroids, chemotherapy/radiation, or RA treatment?*

YesNo
Please specify*

Does the child or family member have a seizure disorder or other nervous system problem? (e.g., Guillain Barre Syndrome or epilepsy)*

YesNo
Please specify*

Name of Parent/Guardian *

First NameLast Name

Name*

First NameLast Name

Birth Date *
mm/dd/yyyy
Sex*

MaleFemale

Primary Phone*
Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

City

Zip Code

Are you feeling sick today?*

YesNo

Have you ever had an allergic reaction (e.g., anaphylaxis) to any medications, vaccines, or foods? (e.g., eggs, latex, polyethylene glycol, polysorbate, or injectable medications)*

YesNo
Please specify *

Have you ever had a serious reaction after a vaccination for which you had to be treated with epinephrine or for which you had to go to the hospital?*

YesNo
Please specify *

Have you received any vaccines in the past 28 days?*

YesNo
Please specify *

Do you have any long-term health condition(s)? Such as heart disease, lung disease, liver disease, diabetes, kidney disease or other?*

YesNo
Please specify *

Are you or someone you live with immunocompromised? (e.g., being treated for cancer, HIV/AIDS, or other immune system problems or taking medication that may weaken the immune system such as prednisone or injectable biologic)*

YesNo
Please specify *

Do you have a bleeding disorder or are you taking a blood thinner? (e.g.,Thrombocytopenia or taking Eliquis, Xarelto, or Warfarin)*

YesNo
Please specify *

Have you had a seizure, or do you have a nervous system problem? (e.g., Guillain Barre Syndrome or epilepsy)*

YesNo
Please specify *

For Women: Are currently or planning (within 30 days) on breastfeeding or becoming pregnant?*

YesNoN/A
Please specify *

Electronic signature *
By entering patient name (parent/guardian if minor), I assert that I have reviewed and agree to "Vaccine Acknowledgement"
Questions: 262-649-3900

Please reach out with any questions. Our team is happy to assist.
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