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Covid Testing & Immunization
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Medicare Part D
Immunizations & Testing
Covid Testing
Vaccinations
Onsite Flu Shot Clinic
Pharmacy Locations
Cambridge
Columbus
Cottage Grove
Deerfield
McFarland
Gifts
Online Refills
Cambridge Refills
Columbus Refills
Cottage Grove Refills
Deerfield Refills
McFarland Refills
Services
Covid Testing & Immunization
Long Term Care
Onsite Flu Shot Clinic
Transfer Prescriptions
Forward Pharmacy
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Forward Pharmacy
Medicare Part D
Immunizations & Testing
Covid Testing
Vaccinations
Onsite Flu Shot Clinic
Pharmacy Locations
Cambridge
Columbus
Cottage Grove
Deerfield
McFarland
Gifts
Online Refills
Cambridge Refills
Columbus Refills
Cottage Grove Refills
Deerfield Refills
McFarland Refills
Services
Covid Testing & Immunization
Long Term Care
Onsite Flu Shot Clinic
Transfer Prescriptions
COVID Vaccination Screening
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
Hidden
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
