Clinic Request Form

Vaccine Clinic Request Form

Request for a Larimer County Department of Health and Environment Vaccine Clinic
We are excited with the prospect of partnering with you. Please complete this short survey to help us learn more about your needs.

Important Notes:
- We request 3 weeks or more advance notice of the event, whenever possible.
- We are an equity-based community clinic provider with the goal of reducing barriers to receiving vaccines. Populations we are able to serve in the community include the following:
  - Uninsured or underinsured individuals ages 6+
  - Individuals with Medicaid ages 6+
  - Individuals requesting COVID-19 vaccination
Please know that not all requests can be accommodated. An LCDHE team member will coordinate with you within 5 business days regarding your request.
Contact Information for Event Coordination:
Primary Contact Name

First NameLast Name
Primary Contact Title
Primary Contact Email
example@example.com
Primary Contact Phone Number
Please enter a valid phone number.
Event Details
Event Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Hosting the Clinic and Population Served by the Event
Date Requested for the Event (Please list multiple dates in order of preference):
Preferred Clinic Start Time

Hour Minutes

AM/PM Option
Preferred Clinic End Time (Preferred 4 hours or less)

Hour Minutes

AM/PM Option
Clinic Site (NOTE: Outdoor requests can be accommodated during the months of May-September and will be canceled for inclement weather):

IndoorsOutdoors
Anticipated number of event attendees:
Anticipated Ages Present for the Event:
Number of 6-11 year olds:
Number of 12-17 year olds:
Number of people 18 years and older:
Additional Event Details
Vaccine(s) requested for the event:
Is Parking Available?

YesNo
What equipment will be provided by the host organization (tables, chairs, power outlets, etc.)
What equipment would need to be provided by Larimer County Department of Health and Environment (LCDHE) (tables, chairs, extension cords, etc.)
Is Internet Access Available?

YesNo
What languages will be spoken at this event? Are interpreters needed?
How many non-medical volunteers will you be able to provide?
How many medical volunteers can you provide? What are their credentials?
Is there anything else you would like us to know?
Should be Empty:

Vaccine Clinic Request Form

Contact Information for Event Coordination:

Event Details

Anticipated Ages Present for the Event:

Additional Event Details