October 9, ADRC - ADULT Seasonal Flu/COVID Vaccination Appointment Form

October 9, ADRC - ADULT Seasonal Flu/COVID Vaccination Appointment Form

To schedule an appointment, please fill out the information below. If you need assistance with scheduling or have questions on eligibility, please call 920-746-2234 or email publichealth@co.door.wi.us.
Vaccine(s) Requested*

Standard Dose Flu (ages 19+)High Dose Flu (ages 65+)Pfizer Comirnaty COVID-19 2025-26 (ages 19+)
Vaccine Payment/Eligibility*

Medicaid/BadgerCare+Medicare Part B (without an advantage plan)Medicare Advantage Plan (Humana or United Healthcare Only for WI*)Commercial Plan (Common Ground or United Healthcare Only for WI*)County of Door Employee or Dependent on the County's insurance planCash or Check ($50 standard flu/$98 high dose flu/$165 COVID-19)Uninsured Adult (19+) Standard Dose Flu Only
At this time, we do not have free COVID-19 vaccine available for uninsured and underinsured adults.
Medicare Part B Member ID #*
XXXX-XXX-XXXX
Insurance Carrier (Medicare Advantage)*
Insurance Carrier (Commercial)*
Member ID #*
*We are not in-network any other Medicare Advantage Plans or Commercial Insurance at this time and unable to bill. We can only accept Advantage and Commercial plans with Wisconsin coverage.

All other insurance plans, please call your doctor’s office, pharmacy, or health insurance company to see where you are covered. Otherwise, cash and check payable to "DCPH" accepted—$50 standard dose/$98 high dose flu/$165 COVID-19. Receipts are provided to submit for reimbursement from your insurance, if needed.
Insurance card(s) and a valid I.D. must be presented at time of appointment.
Please select an appointment time.*
Contact Information
Person Receiving Vaccine(s)*

First NameLast Name
Date of Birth*

MonthDayYear
Age
Phone Number*
Area code required
Email (by providing your email, you consent to receive confirmation and reminders via email)
example@example.com
Additional Notes:
Should be Empty:

October 9, ADRC - ADULT Seasonal Flu/COVID Vaccination Appointment Form

Contact Information