Vaccination Appointment Form

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.
Door County Public Health's vaccination clinic primarily serves children 18 years of age and younger needing routine vaccination who meet one or more of the vaccine eligibility criteria outlined below. Adults must schedule flu and COVID vaccines through public Fall Clinics October-November. In-office appointments are for children and other immunizations during this time.

Specific criteria allows for some vaccines to be offered to those 19 and older, see Additional Eligibility Criteria for Adults.
Vaccine Eligibility - Please select all that apply*

Child Medicaid/BadgerCare+Native American or Alaskan NativeNo Health InsuranceInsured, Vaccines Not CoveredEligible Uninsured or Underinsured Adult (19 and older)Adult Tdap Vaccine (available for ages 19 and older regardless of insurance)Influenza (Flu) Vaccine for Children in Grades 6-12
Cash, check, Traditional Medicare Part B, and United Healthcare Medicare Advantage* accepted; plans issued by Wisconsin only. *No other Medicare supplements accepted other than United Healthcare.

Influenza (Flu) Vaccines: Flu vaccines have a fee of $40 for standard dose and $75 for high dose. The flu vaccine is free for children ages 6 months to 18 years who are on Medicaid/BadgerCare+, have no insurance/insurance that doesn't cover vaccines, or are Native American or Alaskan Native.

COVID Vaccines: We offer Pfizer COVID 2023-24 vaccine for $120. COVID vaccine available free for ages 6 months to 18 years for those who are on Medicaid/BadgerCare+, have no insurance/insurance that doesn't cover vaccines, or are Native American or Alaskan Native. For children who don't qualify, DCPH only has COVID vaccine available for ages 12-18 for a fee.
Note: A nurse will contact you to verify eligibilty prior to your appointment.
Please select an appointment date and time.*
Contact Information

If you have multiple children receiving immunizations, a new form will need to be completed for each child.
Person Receiving Vaccine(s)*

First NameLast Name
Parent/Guardian (if person receiving vaccine(s) is under 18 years old)

First NameLast Name
Parent or legal gaurdian must be present for appointment or provide signed authorization form.
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
Vaccine(s) Requested*

Birth to 18 Months Required VaccinesSchool Required VaccinesCOVID Pfizer 2023-24 for 6 months-18 years onlyDTaP (Diphtheria, Tetanus, Pertussis)Hepatitis AHepatitis B*Hib (Haemophilus Influenzae Type B)HPV (Human Papillomavirus)Influenza (Flu) for 6 months-18 years onlyMeningitisMeningitis B**MeningococcalMMR (Measels, Mumps, Rubella)PneumococcalPolioRotavirusTdap (Tetanus, Diphtheria, Pertussis)VaricellaPlease determine other vaccines needed/available
*Available in combination vaccine.

**Must be ordered by request. Allow at least two weeks when scheduling.
Additional Notes:
Should be Empty:

Vaccination Appointment Form

Contact Information