Caplet Pharmacy Mobile Vaccination Clinic Request Form

Caplet Pharmacy Mobile Vaccination Clinic Request Form

Caplet Pharmacy offers convenient on-site vaccination clinics for organizations such as businesses, schools, and community groups. After submitting an interest form, the team schedules a clinic and provides a HIPAA-secure online signup for participants. Vaccinations are administered onsite by certified staff, with all supplies provided and insurance handled in advance. Clinics can also be opened to family members or the wider community if desired.
Organization Information

Tell us about your organization and primary contact.
Organization Name*
Primary Contact Name*

First NameLast Name
Primary Contact Title / Role
Contact Email Address*
example@example.com
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Clinic Location Details

Provide the address where the vaccination clinic will take place.
Clinic Address (Location of Event)*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Vaccination Preferences

Select the vaccines you wish to offer at your clinic.
FluCOVID-19Tdap (Tetanus, Diphtheria, Pertussis)Pneumonia (Age 50+)Shingles (Age 50+)RSV (Age 50+)Other (please specify)
If 'Other' vaccine, please specify
Clinic Size & Billing

Tell us about the expected clinic size and your billing preference.
Estimated Number of Participants*
Bill individual insurance plansOrganization will cover cost (out-of-pocket)Unsure / Need guidance
Scheduling Preferences

Let us know your preferred days and times for the clinic.
MondayTuesdayWednesdayThursdayFridaySaturdaySundayNo Preference
Preferred Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Alternative Clinic Date(s) if preferred date is not available:
Additional Information

Share any additional notes or questions.
Additional Notes or Special Requests
Optional: Recommended Add-ons for Better Conversion

Enhance your clinic experience with these options.
Employees onlyEmployees + Family MembersCommunity / Public
YesNo
Should be Empty:

Caplet Pharmacy Mobile Vaccination Clinic Request Form

Organization Information

Clinic Location Details

Vaccination Preferences

Clinic Size & Billing

Scheduling Preferences

Additional Information

Optional: Recommended Add-ons for Better Conversion