Concordia University

Vaccination Sign-up Form (Provided at Concordia University, Mequon, WI)

Concordia University is proud to be a source of Pfizer COVID-19 vaccinations. We vaccinate all eligible patients. You do not need to work or learn at Concordia to receive a COVID-19 Pfizer vaccination on our campus. All eligible patients are welcome. Over the Spring and Summer 2021, our healthcare faculty of nurses, nurse practitioners, pharmacists, physician assistants and a physician safely and effectively administered more than 3000 doses of Pfizer vaccine. This Fall 2021 we continue to be committed to providing Pfizer COVID-19 vaccinations to all eligible patients, ages 12 to 100+.

At Concordia, there is no charge for the vaccine or our services. We do not ask for insurance information. If you have questions or concerns, we are licensed health care providers and are happy to help. We are engaged in vaccination efforts for one reason - to serve our communities through safe and effective access to the Pfizer COVID-19 vaccine.

If you are interested in receiving the vaccine, all you need to do is complete the form below. If you have any questions, concerns, or problems signing up, please feel free to contact Mike Brown, PharmD, clinical pharmacist and faculty at Concordia University at michael.brown@cuw.edu. My colleagues and I are excited to serve you. We look forward to seeing you soon for vaccination.

First Name:

Last Name:

Cell Phone Number:

Email:

Number of Persons to Be Vaccinated (If more than 1, please include names in the NOTES field):

Preferred Date and Time:

Location will be given on next confirmatory page. Location is subject to change.

Notes:

Prior to your vaccination, please review the following information. Both the Consent Form and the Screening Form may be completed ahead of time and brought along. Extra copies will available on-site if the form is not completed.

  1. Pfizer-BioNTech COVID-19 Vaccine Fact Sheet for Recipients and Caregivers
  2. Vaccination Consent Form (if under 18 years old, required parent/guardian signature)
  3. COVID-19 Screening
  4. Map of Concordia University (12800 North Lake Shore Drive, Mequon, WI 53097)

The Pfizer vaccine is a two-dose series, with the second dose at least 21 days after the first dose. The timing of your second dose will be arranged at your first dose appointment.

As of August 13, 2021, a third dose of Pfizer at least 28 days after your second dose is authorized for patients with conditions that are immunocompromising. Third doses are not approved for all patients at this point in the EUA. Concordia providers do recommend that you have a conversation with your provider responsible for treating your immunocompromsing condition regarding whether you would benefit from a third dose. We do not need any documentation but simply your verbal confirmation that a conversation with your provider occurred and that the vaccine is recommended for you.

For both adults and for children 12-17 years old, getting vaccinated is as important as ever because:

Looking for more information? More information can be found at Pfizer-BioNTech COVID-19 Vaccine Fact Sheet for Recipients and Caregivers and at CDC Interim Public Health Recommendations for Fully Vaccinated People.

If you have questions, please do not hesitate to contact Mike Brown, PharmD, at michael.brown@cuw.edu or at 262-243-2761.

Concordia University Vaccination Health Provider Team

Mike Brown, PharmD, Professor and Associate Dean of the School of Pharmacy
Renee Gosselin, MSN, RN, Student Health Center
Dawn Kuerschner, PhD, MSN, APN-BC, CNE, Professor and Chair Undergraduate Nursing Programs - Mequon
Pollyanna Kabara, EdD, MS, PA-C, Professor and Director of the Physician Assistant Studies Program
Courtney Muche, BS, Student Pharmacist (P3)
Ernest Stremski MD, MBA, Professor and Student Health Center Physician Supervisor