* VACCINE CLINIC (General Interest)

Hello Community Partner!

Thank you for selecting Good Day Pharmacy to host a vaccination clinic!

We're eager to collaborate with you by coming to your location. This will ensure that you, your employees, and the people in your care can stay safe and well-protected this season.

Please fill out the form below. A separate form is required for each individual physical address.
Type of Business

Assisted Living / Memory Care CommunityEmployer (Vaccines for your employees/staff)Independent Living CommunityOther
Name of Community or Business*
Please complete a separate form for each community location.
Point of Contact Name*

First NameLast Name
Point of Contact Phone Number*
Point of Contact Email*
example@example.com
Community or Business Address*

Street Address

Street Address Line 2

CityState
ON-SITE VACCINE CLINIC
Flu vaccine clinic?*

YESNO
Number of residents / staff needing the 'STANDARD' Flu Vaccine (under age 65)? *
Number of residents / staff needing the 'HIGH DOSE' Flu Vaccine (over age 65)? *
Pneumonia (Prevnar 20) Vaccine Needed?*

YESNO
Number of residents / staff needing the Prevnar 20 Vaccine? *
Moderna/Covid*

YESNO
Number of residents / staff needing MODERNA Vaccine?*
Shingrix*
Number of doses needed
RSV*
Number of doses needed for above vaccine
THANK YOU

Our Vaccine Clinic Team will be in contact with you.
Should be Empty:

ON-SITE VACCINE CLINIC