On-Site Vaccination Clinic Inquiry Form

1

What best describes your organization?* This field is required.

Business

Assisted Living

Group Home

School

Other

2

Name of contact person for the organization* This field is required.

First Name

Last Name

Job Title

3

Email

example@example.com

4

Phone Number* This field is required.

Please enter a valid phone number.

5

Preferred contact method?* This field is required.

Call

Email

Text

6

Address for clinic to be held at* This field is required.

Organization Name

Street Address

City

State

Zip Code

Country

8

How many expected patients? (minimum 15)

9

Will this be a multi-day clinic?

YESNO

10

Is there a preferred date(s) to hold the clinic?

YESNO

11

Preferred date(s) or day(s) of the week:

12

Is there a preferred time of day for the clinic?* This field is required.

Morning

Afternoon

Evening

No Preferrance

13

Questions, comments, concerns, notes: