DEV: COVID & Flu Services

Admin: Status

This field is hidden and not for public use. Change status to "Invited" to send an invite to a user to schedule a vaccine.

Status Notes

Alerts (admin)

current date

Date

I would like to schedule:

COVID VaccineCOVID TestFlu VaccineOther Vaccine

Are you seeking a COVID-19 test for your employer?

YesNo

Employer ID

Employee ID# (if applicable)

Company Name

Main Contact Name

Is the company name above your employer?

YesNo

When you arrive, remain in your car. DO NOT ENTER THE STORE.
Cuando llegues, quédate en tu coche. NO ENTRE A LA TIENDA.

Please enter the name of your employer in the company name field. Please note, if your employer is not registered with Streu's Pharmacy for COVID-19 testing, we will not be able to accommodate your testing needs.

Please complete the form below and we will contact you to schedule an appointment. You may also call our Nursing Department at 920-593-2465. Thank you!

Streu's has other vaccines available, however we cannot currently schedule them online. Please fill out the form below and we will contact you to schedule an appointment.

I'm interested in the following vaccines:

Shingrix (Shingles Vaccine)Pneumovax (Pneumonia)Td (Tetanus Diphtheria)Tdap (Tetanus Diphtheria Pertussis)

Patient Date of Birth*

Date

Age

Streu's Pharmacy is currently limited to COVID-19 tests for employer referrals. At this time COVID-19 testing is provided to the general public by Wisconsin COVID Connection.

COVID-19 testing is not available for children under 1 year old.

Have you registered for COVID Connect using the link above?

YesNo

Please complete the form below and we will contact you to schedule an appointment. You must additionally register at the COVID Connect link above. Failure to register may delay your test.

What type of COVID Vaccine?*

COVID Booster or additional doseFirst-Time COVID Vaccine

Streu's Pharmacy is currently not offering the COVID-19 Vaccine to individuals under the age of 12. We apologize for the inconvenience.

Current CDC guidelines state anyone ages 12 and older can get a booster shot.

Those who originally received Pfizer-BioNTECH or Moderna may receive a booster 6 months after their 2nd dose.

Johnson & Johnson vaccine recipients may receive a booster 2 months after their initial dose.

View full CDC recommendations

People should talk to their healthcare provider about their medical conditions, and whether getting an additional dose is appropriate for them.

Based on the above criteria from the CDC, do you qualify for a COVID booster vaccine?*

YesNo

CDC guidelines are changing daily. While you may not qualify for a COVID booster now, you may in the near future. Complete the following form and we will contact you when the booster is available for your current status.

Select the date you received the 2nd dose of the COVID-19 vaccine*

Date

Calculated Booster Eligible Date

Date

Based on your answer above, you may qualify to receive a booster on or after {calculatedBooster}

Please select a date and appointment time on or after this date. PLEASE BRING YOUR WHITE VACCINATION CARD IF POSSIBLE TO BE UPDATED.

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Language*

Gender*

Race (Please choose one)*

Ethnicity (Please choose one) *

Hispanic or LatinoNon-Hispanic or LatinoPrefer not to answer

Are you pregnant?*

YesNo

In the last month, have you been in contact with someone who was confirmed or suspected to have Coronavirus / COVID-19? *

YesNoUnsure

Have you had a COVID-19 viral test in the last 14 days?*

Do you have any of the following new or worsening symptoms?

When did your symptoms start?

Have you travelled internationally in the last month?

YesNo

Parent/legal guardian consent for minors*

	Yes
I understand as a minor I must be accompanied by a parent or legal guardian

Have you filled a prescription with Streus Pharmacy in the past six months?*

YesNo

Appointment*

Insurance Card

Please upload/take a picture of the front and back of your insurance card, OR plan to bring it to your appointment.

Acknowledgement and Consent*

	Yes
I understand that I may be asked to provide documentation to confirm my responses above (paycheck stub, employee ID).
I understand that my failure to provide documentation may prevent me from getting my COVID-19 vaccine.
I consent to electronic communications (including, but not limited to email, text message, phone) to schedule and confirm COVID-19 vaccine appointment.

Confirm the following terms & conditions*

	Yes
I understand that my failure to provide documentation may prevent me from getting my vaccine.
I consent to electronic communications (including, but not limited to email, text message, phone) to schedule and confirm my vaccine appointment

Future communications*

	Yes	No
I consent to future non-vaccine-related communications from Streus Pharmacy Bay Natural for marketing purposes.