Washington Island Vaccination Appointment Form

Washington Island Vaccination Appointment Form

Door County Public Health offers vaccines at the Washington Island Community Center on the first Thursday of every other month (even months) by appointment only. 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.

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 Enrolled or EligibleNative 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)COVID-19 Vaccine (available for ages 6 months and older regardless of insurance)Influenza Vaccine
Influenza (Flu) Vaccines: Flu vaccines have a fee of $40 for standard dose and $75 for high dose. Exact cash, check, Medicare Part B*, Humana Medicare Advantage*, and United Healthcare Medicare Advantage* accepted. *We can only accept Medicare plans issued by Wisconsin, Illinois, and Minnesota. The flu vaccine is free for children ages 6 months to 18 years who are on BadgerCare, have no insurance/insurance that doesn't cover vaccines, or are Native American or Alaskan Native.
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-19 Pfizer Primary or Booster (6 months and older)DTaP (Diphtheria, Tetanus, Pertussis)Hepatitis AHepatitis B*Hib (Haemophilus Influenzae Type B)HPV (Human Papillomavirus)Influenza Standard Dose (6 months and older)Influenza High Dose (65+ only)MeningitisMeningitis B**MMR (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:

Washington Island Vaccination Appointment Form

Contact Information