Vaccine Registration Form

Vernon County Health Department

318 Fairlane Drive, Viroqua, WI 54665
Vaccine Registration Form

***If registering for a child, please put child's name on form***
Name*

First NameLast Name
Parents name
Birth Date*

MonthDayYear
Date
FemaleMale
Email
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
No insuranceMedicaid (state insurance)MedicareCommercial insurance (insurance through employer)
Please contact the Health Department at 608-637-5251 to discuss scheduling options with commercial insurance.
Tetanus (Dtap, Tdap, Td)HIBMeningitisFluCOVIDVaricella (Chicken Pox)MMR (Measles, Mumps, Rubella)PneumoniaRoutine childhood immunizationsUnsureHepatitis AHepatitis B
Appointment
Should be Empty: