Boscobel Pharmacy and Center Pharmacy COVID Vaccination Request Form
Effective April 5th, Wisconsin has opened up vaccine availability to all persons 16 and over. We have vaccine available!

Please note that completing this form does not guarantee that you will receive vaccine.

The team from Center Pharmacy and Boscobel Pharmacy will contact you via email or phone to notify you when you are eligible to book your vaccine appointment as the vaccine becomes available.
Patient Name
Email
Age
DOB
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Phone Number
Are you a current patient of Center Pharmacy (formerly Thrifty White Richland Center)?
Clear selection
Are you a current patient of Boscobel Pharmacy?
Clear selection
Our pharmacy has access to the Johnson&Johnson Vaccine. Would you prefer to be put on request list for this one?
Clear selection
Because the supply of COVID-19 vaccine in the United States is expected to be limited at first, the CDC is providing recommendations to federal, state, and local governments about who should be vaccinated first. CDC’s recommendations are based on recommendations from the Advisory Committee on Immunization Practices (ACIP), an independent panel of medical and public health experts. The recommendations were made with these goals in mind: *Decrease death and serious disease as much as possible. *Preserve functioning of society. *Reduce the extra burden COVID-19 is having on people already facing disparities. * * Center Pharmacy will follow the Wisconsin COVID-19 Vaccination Phase guidance: https://www.dhs.wisconsin.gov/covid-19/vaccine-about.htm
Please choose the DHS eligibility group that best reflects your situation. *
Required
Please provide additional information or context that you feel might be relevant including appointment availability.
It is the perfect time to be up-to-date with your vaccines. Center Pharmacy has a variety of vaccine offerings of which most are covered by your prescription plans. If interested in learning more about or receiving any of the below, please select (otherwise leave blank). CDC Vaccine Schedule: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf
DISCLAIMER: please note that your submission of a response to this survey does not guarantee that you will receive a vaccine. We are following the strict CDC and WI DHS guidelines on prioritization of vaccination. We kindly ask that you do not contact the pharmacy for an update on when you will be getting your vaccine. We assure you that you will be contacted AS SOON AS you are eligible for the vaccine - and we have vaccine in stock. THANK YOU for your patience and understanding! *
DATA: Data from this form will not be shared however, I acknowledge & give consent to Center Pharmacy to communicate with me via phone or email. *
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