On-Site Remote Vaccine Clinic Inquiry
Company/Organization Name:
Clinic Location/Worksite Address:
Primary Contact Name:
Title/Position:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Vaccines Requested
Influenze (flu)
COVID-19
Tdap
RSV
Pneumonia
Shingles
Other
Estimated Number of Employees/Participants:
Fewer than 25
25-49
50-99
100-199
200+
Unsure
First Choice Preferred Clinic Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Second Choice Preferred Clinic Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Clinic Start Time
Hour Minutes
AM
PM
AM/PM Option
Are multiple shifts or clinic times needed?
Yes
No
Unsure
Payment & Billing
How would you prefer vaccines to be paid for?
Employer pays for all vaccines
Hillcrest Pharmacy bills participants' insurance when elibible
Combination of employer payment and insurance billling
Unsure -- please discuss options with us
Additional Information
Please provide any additional information that would help us plan your clinic, including shift changes, anticipated high-volume periods, employee language needs, site access requirements, or other special considerations:
Submit
Should be Empty: