Community Pharmacy Vaccination Clinic Inquiry
Thank you for your interest in our mobile vaccination clinic!
Facility/Company/Business Name
*
Name of Primary Contact
*
Primary Contact Title
*
Contact E-mail Address
*
example@example.com
Conact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address of the Clinic Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select which vaccines you would like us to offer (select all that apply)
*
Influenza
COVID-19
Other
Estimated number of patients to receive a vaccine at the clinic
*
Would you like us to bill insurance or will the company/facility pay out of pocket?
*
Bill prescription/medical insurance
Company will pay out of pocket
Unsure
Will the company pay for any vaccine that are not covered by insurance?
*
Yes
No
Unsure
Which day of the week typically works best for your team? (select all that apply)
*
Monday
Tuesday
Wednesday
Thursday
Friday
What time of day is best?
*
Morning
Afternoon
If you have a particular date in mind, please select here. If that date is not available, we are likely fully booked, but please make a not below and we can check to see what we can do!
-
Month
-
Day
Year
Date
What time would you like the clinic to start?
Will you have employees available on the day of to help facilitate the clinic?
*
Yes
No
Unsure
Additional Scheduling Notes and Questions
Submit
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