October 6, Public Health Office - Seasonal Flu/COVID Vaccination Appointment Form

Vaccine(s) Requested

Vaccine Payment/Eligibility

At this time, we do not have free COVID-19 vaccine available for uninsured and underinsured adults.

*We are not in-network with 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/$100 high dose flu/$175 COVID-19. Receipts are provided to submit for reimbursement from your insurance, if needed.

Insurance card(s) must be presented at time of appointment.

Medicare Part B Member ID #

XXXX-XXX-XXXX

Insurance Carrier (Medicare Advantage)

Insurance Carrier (Commercial)

Member ID #

Child(ren)

Our fall flu/COVID-19 clinic dates are primarily intended to serve adults. We offer a regular in-office vaccine clinic on Wednesdays, primarily for children.

If you are scheduling for yourself and have an eligible child or children you would like to receive flu vaccine (available for ages 6 months–18 years) and/or a COVID-19 vaccine (available for ages 6 months+ depending on eligibility), we will do our best to accommodate your request during your scheduled appointment.

Please list their name(s), date(s) of birth, and vaccines requested.

Please select an appointment time.

Person Receiving Vaccine(s)

First NameLast Name

Date of Birth

MonthDayYear

Age

Phone Number

Area code requiredFormat: (000) 000-0000.

Email (by providing your email, you consent to receive confirmation and reminders via email)

example@example.com

Additional Notes:

October 6, Public Health Office - Seasonal Flu/COVID Vaccination Appointment Form

Contact Information