Vaccine Clinic Registration Form
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Contact Name
*
First Name
Last Name
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact Email
*
example@example.com
Which vaccines are your company interested in? (Select all that apply)
*
Covid-19 Vaccine
Influenza Vaccine (Under age 65)
High Dose Influenza Vaccine (Ages 65+)
Other
Who are the vaccinations for? (Select all that apply)
*
Employees
Customers
Patients
Family Members
Other
Will there be any patients under the age of 18? *Please note: Paul's Pharmacy does not vaccinate children under the age of 11*
*
Yes
No
Approximate Number of People Receiving Vaccines
*
Vaccine clinics are typically scheduled in September or October. Which month is your company interested in?
*
September
October
Other
Are there any specific days or times that work best for your company?
*
Comments, Questions, or Concerns?
Submit
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