Request on site Vaccination Clinic
Please provide all required details for this request. We will do our best to secure your community a spot on our schedule if we are able to accommodate your request after servicing our partnering communities.
Business Name
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name for Community
*
Contact Number
*
E-mail
*
example@example.com
Type of Business
*
Please Select
Assisted Living or Memory Care Community
Adult Family Home
Supported Living Community
Behavior or Mental Health Facility
Jail or Detention Facility
Other Business
Business
How many staff and clients are you hoping to have vaccinated?
What vaccinations are you interested in offering to your community? Please check all that apply.
Flu Shot
COVID Shot
RSV
Prevnar 20
Please provide any other details that may be helpful to us?
Submit
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