Employer COVID-19 Vaccine Interest Form

Getting vaccinated against COVID-19 is one of the best ways to protect yourself and everyone around you. When a vaccine becomes available to you, you can count on Workforce Health to offer safe and easy ways to receive it.

Vaccine doses will be offered at no cost. There is an administration fee to be vaccinated. It is, however, covered by all major health insurers. Froedtert & MCW health network will not bill uninsured patients for the administration fee. There will be no out-of-pocket costs to individuals for the vaccine or administration.

EDUCATORS: Do not complete the form below. Please contact your local health department for vaccine information.

Other employers, to register your company for COVID-19 vaccinations, fill in the following fields.

Primary Contact

Do you have a current Occupational Health Services contract with Workforce Health?
Types of employees being vaccinated

Use your mouse or fingertip to sign above.
Enter the characters shown in the image.
Get new captcha!