RSV Interest Form for Children

RSV Interest Form for Children
Child's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
My child's insurance is:*

Commercial Insurance (through an employer)State Insurance (Medicaid, BadgerCare, State Insurance)Health share plan (Medishare, Libertyshare, etc)No Insurance
The name of my child's insurance is: *
Child's Date of Birth*

MonthDayYear
Date
Does your child have any increased risk factors as outlined by the CDC? https://bit.ly/3tM9yWO If so, please list. *
How many weeks was your baby born at (weeks gestations)?*
Given news of a severe shortage of the RSV immunization, Beyfortus, for infants, Tosa Pediatrics is prioritizing those at highest risk for RSV complications. We will begin by immediately immunizing those under 1 month of age and those under 2 months of age but born prematurely who are not receiving Synagis while supplies last. (Synagis prevents RSV in premature infants born at 28 weeks and under and in other special circumstances. If your child receives Synagis, there is no need to receive further RSV immunization.)

While we cannot guarantee we will have inventory, we will place your child on a prioritization list and email you when ready to immunize. Please do not call the office. Thank you for your understanding.

We ask that you review details including side effects and risks in advance. To learn more about Beyfortus, go to wwwbeyfortus.com or review information on the CDC at https://bit.ly/3tM9yWO
Date*

MonthDayYear
Date
Signature

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