LTC Scripts Vaccination Clinic Request

Facility Name

Facility Type

Facility Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Is your facility currently serviced by LTC Scripts?

Primary Contact Name

First NameLast Name

Title

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Coordinator Name

Coordinator Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Clinic Date

Date

Alternate Clinic Date

Date

Clinic Type

Vaccines Requested

If Other, please specify vaccine

Estimated Participants - Residents

Estimated Participants - Employees

Total Expected Vaccinations

To help us prepare your vaccination clinic, please upload any available participant documentation. Examples include completed vaccination consent forms, resident face sheets, insurance information, copies of insurance cards, participant lists, or other documents needed for patient registration and insurance verification. If these documents are not yet available, they may be submitted later.

Facility Responsibilities

Please review the responsibilities below before submitting your vaccination clinic request.

To help ensure a successful vaccination clinic, the facility agrees to:

• Designate a primary contact person and day-of-clinic coordinator.

• Assist in promoting the vaccination clinic to residents, staff, family members, and responsible parties, as appropriate.

• Distribute educational materials and consent forms provided by LTC Scripts.

• Encourage participation by eligible residents and employees.

• Provide completed vaccination consent forms, resident face sheets (or equivalent demographic information), insurance information, copies of insurance cards (when applicable), and any additional documentation reasonably requested by LTC Scripts.

• Submit all available participant information at least seven (7) business days prior to the clinic whenever possible.

• Provide a suitable clinic area and assist with resident flow during the event.

• Notify LTC Scripts promptly if the clinic must be postponed or rescheduled.

Authorization

Authorized Representative

Title

Electronic Signature

Date

I certify that I am authorized to submit this request on behalf of my facility and that the information provided is accurate.

LTC Scripts Vaccination Clinic Request

Facility Information

Primary Contact

Day-of-Clinic Coordinator

Clinic Details

Authorization