Brookfield Vaccine Center
Vaccine Check-in
Please Select Patient Age
*
6-11 Years
12+ Years
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Child's Full Name
*
First Name
Last Name
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Child's Birth Date
*
mm/dd/yyyy
Sex
*
Male
Female
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Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Is the child feeling sick today?
*
Yes
No
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Has the child ever had an allergic reaction (e.g., anaphylaxis) to any medications, vaccines, or foods? (e.g., eggs, latex, polyethylene glycol, polysorbate)
*
Yes
No
Please specify
*
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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?
*
Yes
No
Please specify
*
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Has the child received any vaccines in the past 56 days?
*
Yes
No
Please specify
*
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Does the child have any long-term health condition(s)? For example: heart disease, lung disease, liver disease, diabetes, kidney disease, bleeding disorder)
*
Yes
No
Please specify
*
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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)
*
Yes
No
Please specify
*
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In the past 3 months has the child taken a medication that affects the immune system such as steroids, chemotherapy/radiation, or RA treatment?
*
Yes
No
Please specify
*
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Does the child or family member have a seizure disorder or other nervous system problem? (e.g., Guillain Barre Syndrome or epilepsy)
*
Yes
No
Please specify
*
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Please check vaccine(s) patient will be receiving
*
Flu shot
Covid (Pfizer)
Covid (Moderna)
Tetanus
HPV
Pneumonia
MMR
Typhoid
Hepatitis A/B
Polio
MenACWY
For MMR Vaccine ONLY: Has the child recently (≤11 months) received an antibody-containing blood product?
*
Yes
No
For MMR Vaccine ONLY: Is the child completing a TB skin or blood test in the next month?
*
Yes
No
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Name of Parent/Guardian
*
First Name
Last Name
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Name
*
First Name
Last Name
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Birth Date
*
mm/dd/yyyy
Sex
*
Male
Female
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Next
Primary Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Next
Are you feeling sick today?
*
Yes
No
Back
Next
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)
*
Yes
No
Please specify
*
Back
Next
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?
*
Yes
No
Please specify
*
Back
Next
Have you received any vaccines in the past 28 days?
*
Yes
No
Please specify
*
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Next
Do you have any long-term health condition(s)? Such as heart disease, lung disease, liver disease, diabetes, kidney disease or other?
*
Yes
No
Please specify
*
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Next
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)
*
Yes
No
Please specify
*
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Do you have a bleeding disorder or are you taking a blood thinner? (e.g.,Thrombocytopenia or taking Eliquis, Xarelto, or Warfarin)
*
Yes
No
Please specify
*
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Have you had a seizure, or do you have a nervous system problem? (e.g., Guillain Barre Syndrome or epilepsy)
*
Yes
No
Please specify
*
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For Women: Are currently or planning (within 30 days) on breastfeeding or becoming pregnant?
*
Yes
No
N/A
Please specify
*
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Please check vaccine(s) you’d like to receive
*
Flu shot
Shingles
TDAP
Covid (Pfizer)
HPV
MMR
Covid (Moderna)
Typhoid
RSV
Hep A/B
Polio
MenB
MenACWY
Pneumonia
For COVID Vaccine: Have you received treatment for COVID-19 in the past 90 days or a vaccine for COVID-19 in the past 2 months?
*
Yes
No
For MMR Vaccine: Are you planning on completing a TB skin or blood test in the next month?
*
Yes
No
For MMR Vaccine: Have you recently (≤11 months) received an antibody-containing blood product?
*
Yes
No
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Electronic signature
*
By entering patient name (parent/guardian if minor), I assert that I have reviewed and agree to "Vaccine Acknowledgement"
Submit
Questions: 262-649-3900
Please reach out with any questions. Our team is happy to assist.
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