Immunization Clinic Inquiry
Hereford Pharmacy provides a professional, efficient, and friendly vaccination experience through our mobile clinic service! Your employees will fill out our HIPAA-secure intake form before the clinic even happens to streamline the process even further. We can bill insurance or provide competitive out-of-pocket options. Hereford Pharmacy supplies all required materials and personnel so you can relax and feel confident that you've provided your employees with a valuable service!
Name of Primary Contact
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Business Name
Business Address (location where clinic will be held)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Approximate number of people receiving vaccinations
Would you like us to bill insurance or will the company be paying out of pocket?
Bill Insurance
Pay out of pocket
Unsure
If you chose 'bill insurance' above, will the company cover the cost of vaccinations not covered by your employees insurance?
We will cover the cost if needed
The employee will be responsible for paying
Unsure
What insurance carrier does your company use to insure its employees?
Do you have a preferred date in mind? (September 1st to October 31st)
-
Month
-
Day
Year
Date
Special scheduling requests or other questions?
Submit
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