Vaccine Clinic Request Form
My Pharmacy and Optical
Your Name
*
First Name
Last Name
Facility/Event Location Name
*
Facility/Event Location Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell phone for texting our clinic coordinator
Please enter a valid phone number.
Email
*
example@example.com
If you are a LTC facility, what areas are to receive vaccinations?
Assisted Living
Memory Care
Skilled Nursing
Independent Living
Other
Requested Vaccines (for LTC: we will check eligibility for each resident)
*
Covid
Flu
RSV
Tdap
Shingles
Pneumonia 20
Other
Any other info we need to know?
Submit
Should be Empty: