COVID-19 and Influenza Vaccine Clinic Preregistration Form
Please enter the following information and select a date to reserve the date for your organization's Vaccine Clinc for this season. Please enter an estiamted number of vaccines you may need in order for us to ensure we have enough vaccines prior to the selected date.
Organization Name
*
Primary Contact Name
*
First Name
Last Name
Primary Contact Email
*
example@example.com
Primary Contact Phone Number
*
Please enter a valid phone number.
Organization Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date for Clinic
*
-
Month
-
Day
Year
Date
Estimated Number of Influenza Vaccines Needed
*
Estimated Number of COVID-19 Vaccines Needed
*
Submit
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