On-Site Immunization 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
Flu
Covid
RSV
Pneumonia
Meningitis
Tdap (Tetanus)
Other
Estimated Number of Employees/Participants:
1-9
10-29
30-49
50 or more
Not Sure
First Choice of Clinic Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Second Choice of Clinic Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Will you need multiple shifts/clinic times?
How would you prefer to pay for the vaccines?
Employer pays for all vaccines
The Drug Store bills patient's insurance (if eligible)
Combination of employer payment and insurance billing
I'm not sure. Call or email to discuss.
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: