On-Site Remote Vaccine Clinic Inquiry
Company/Organization Name:
*
Business Location (Address and/or Site Description)
*
Primary Contact Name:
*
Title/Position:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Vaccines Requested
*
Influenza (Flu)
Pneumonia
Shingles
RSV
Tetanus
Hepatitis B
COVID-19
Meningitis
Other
Estimated Number of Employees/Participants:
*
Fewer than 10
11-24
25-49
50-99
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
Does your business have a group insurance plan?
*
Yes
No
If your business DOES have a group insurance plan, please upload a photo of your insurance card.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If you do NOT have a group insurance plan, how would you prefer vaccines to be paid for?
*
Employer pays for all vaccines
Your Hometown Pharmacy bills participants' insurance if eligible
Combination of employer payment and insurance billing
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 Inquiry
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