LIVE: Streu's - 2025 Vaccine Request

Streu's Community Pharmacy is closed and no longer able to provide vaccines for the general public. Facilities may contact our Long-Term Care Pharmacy nursing team to inquire about vaccine clinics at 920-593-2467.
Which vaccine(s) are you interested in?*

FluCOVID-19Shingrix (shingles)Prevnar 20 (pneumonia)Td (tetanus, diptheria)Tdap (tetanus, diptheria, pertussis)Other
Patient Type
Status Notes
This field will be hidden when live for public use. It is a field that a Streu's scheduler can optionally use to add additional notes to a specific submission record from a user.
Patient Name*

First NameLast Name
Patient Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email*
example@example.com
Patient Date of Birth*

MonthDayYear
Date
Age (calculated)
Date

MonthDayYear
Date
Date

MonthDayYear
Date

ATTENTION: Minors (age 17 or under) require a parent/legal guardians consent for minors*

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

Please call our Nursing Team at 920-593-2465 to determine availability for flu vaccines for minors. Thank you!
Have you filled a prescription with Streu's Pharmacy in the last six months?

YesNo
Insurance Card

Please bring your insurance card to your appointment.
Upload from computer or device files

Cancelof
Take a photo with your mobile device
Appointments - 9/26/22 and 10/3/22

Confirm the following terms & conditions*

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

Future communications consent*

Rows	Yes	No
I consent to future non-related communications from Streu's Pharmacy Bay Natural for marketing purposes.