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Skip to Content
Immunizations
Book a Vaccination Appointment
Onsite Flu Clinic
Rapid Testing
Medicare Part D
Travel
Long Term Care
Gifts
Online Refills
Cambridge Refills
Columbus Refills
Cottage Grove Refills
Deerfield Refills
McFarland Refills
Monona Refills
Pharmacy Locations
Cambridge
Columbus
Cottage Grove
Deerfield
McFarland
Monona
Transfer Prescriptions
COVID Vaccination Screening
Δ
Screening Questionnaire for Immunization
Name
(Required)
First
Last
Email
(Required)
Are you sick today? (Fever, cough, shortness of breath, nausea/vomiting in the last 24 hours)
(Required)
Yes
No
Have you received antibody therapy or convalescent plasma for COVID treatment in the past 90 days?
(Required)
Yes
No
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Have you received a vaccine in the past 14 days?
Yes
No
Which vaccines? Please list the name and dates, along with any other information.
(Required)
Are you currently in your isolation or quarantine period due to COVID-19?
(Required)
Yes
No
Have you received a dose of the COVID vaccine?
(Required)
Yes
No
Which brand of vaccine?
(Required)
Which date did you receive vaccine?
(Required)
MM slash DD slash YYYY
