Times Pharmacy Vaccination Service Request

Times Pharmacy Mobile

On-site Vaccination Clinic Service Request
Please complete each section to the best of your ability.
1. Point of Contact Name:
Phone number:
Contact Number
Email

Confirmation Emailexample@example.com
2. Location Name
Business/Facility/School name
2. Location Address
Event Date/Time requesting:
Our mobile teams service island wide. We do our best to schedule our clinics when they are requested. We ask for multiple dates and times, we will do our best to accomodate your business/School.
1st option:
Start time:
TBD if unsure
End time:
TBD if unsure
2nd option:
Start time:
End time:
3rd option:
Start time:
End time:
5. Health Insurance Carrier(s)
6. Vaccinations wanted:
7. Number of Recipients:
(15 minimum, Family members are welcome)
8. Additional Info, Notes, Parking info
9. Suggestions or Special Requests
Pualani Moefu

Business Clinic Coordinator

(808)832-8265

Times Pharmacy Office

1620 N. School Street

Honolulu, HI 96817

timesvaccines@times-supermarket.com
Should be Empty:

Times Pharmacy Mobile