Vaccine Clinic Interest Form
Thank you for your interest in our vaccine services! Please complete the form below and our team will connect with you to share details and next steps.
Name of person completing this form
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of the business
*
What is your title and role with this business
Address where the clinic would be located
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of business is requesting a clinic?
*
Self-Insured Employer
Fully-Insured Employer
School District
Adult Care Facility
Other
Approximately how many vaccine recipients do you estimate
*
Fewer than 20
20-30
31-50
51-100
101-150
More than 150
What vaccines are needed? (Select all that apply)
*
Seasonal Influenza
COVID-19
RSV (ages 75 and older)
Other - Give details below
If other listed above, what other vaccines are you interested in?
What questions would you like us to address when we share more details on the vaccine program?
How did you hear about us?
Submit
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