Skippack Pharmacy Mobile Vaccination Clinic

Skippack Pharmacy Mobile Vaccination Clinic

Bring vaccines directly to your workplace, school, church, or community event. Complete this quick form and our team will help coordinate a mobile clinic date, vaccine options, and a seamless on-site experience for your group.
This form is for ORGANIZATIONS inquiring about our mobile vaccination services only. If you are an individual looking to receive a vaccine please refer to our website for upcoming community vaccination events near you. You can also sign up for a vaccination at Skippack Pharmacy on our website or walk in today!
How it works:

After filling out this Skippack Pharmacy Mobile Vaccination Clinic interest form, our team will schedule a date and time that works best for you and your organization. A HIPAA-secure, online consent and sign-up form will be sent to you via email. It should be filled out by participants who want a vaccine prior to the clinic. This allows us to obtain the information of each individual who will be receiving a vaccine. Then we can bill insurance and solve any issues ahead of time. On the day of the clinic, our immunization certified team members will come to your location and administer the vaccines onsite. We provide all necessary supplies and ensure a clean, safe environment.
What type of organization are you representing?
Organization, Government Office, School, Business, or Facility Name
Name of Primary Contact

First NameLast Name
Primary Contact Title
Contact Email Address
example@example.com
Contact Phone Number

Area CodePhone Number
Please provide the school nurse, health coordinator or other staff member who should be included in clinic planning (Name, title, email, phone number)
How did you hear about us?
What is the best way to contact you?
Are you requesting support for an existing event or planning a standalone vaccination clinic?
Event or Clinic Name
Event Date
Date
Start and End Time
Which day of the week typically works best for your organization?
What time would you like to start the clinic?

:HourMinutesAM/PM Option
What time of day works best?

Other
Please list any dates that you would be interested in having the vaccine clinic on.
Are vendor or community-partner applications currently open?
Vendor Confirmation Deadline
Is this an annual event?
Clinic Address (where the clinic will be located)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What type of event is it?

Other
What type of event is this?

Other
Is the event open to the public?
What age groups are expected?
Estimated number of people to receive a vaccine at the clinic
Is another pharmacy, health system or vaccination provider participating?
Who may participate?

Other
Who may participate?

Other
Who should be eligible to participate?

Other
How many shifts or locations may need to be supported?

Other
Please briefly describe the locations, shifts, or times we may need to accommodate.
What type of community or facility is this?
Who should be eligible to participate?

Other
Is another pharmacy or healthcare provider currently providing vaccination services?
Would you still like to discuss services that could complement your current provider?
What would you like Skippack Pharmacy to provide?
Please select which vaccines you would like us to offer (select all that apply)

Other
How would you like us to bill the vaccines?
Are you interested in VFC-supported pediatric vaccination services?
Would you like Skippack Pharmacy to provide a customized registration link?
Which resources can the host provide?
Does the venue require any of the following?
How can your organization distribute registration info before the event?
May Skippack Pharmacy help promote the event through its community network and social media?
Additional Notes
Please share any additional information, special requirements or questions.
Should be Empty: