Fall 2024 Vaccine Clinic Interest Form
Please fill out the following form in its entirety.  Note, completion of this form is NOT A CONFIRMATION for your requested clinic. A member of the pharmacy staff will contact you for further details before a final clinic date is set. PLEASE NOTE WE DO NOT PROVIDE THE SPACE OR FACILITY TO HOST THE CLINIC. WE COME TO YOU.

Clinics will be scheduled from late August through early December of 2024. While we provide this service as well as all clinic supplies for free, we ask that staff explain to participants that they will need updated insurance information to participate. All insurance will be processed before the day of the event. Cash pricing for uninsured/insurance-rejected participants is available upon request. 

PLEASE NOTE:
  • Please see image below for explanation of insurance coverage for immunizations. This will also be emailed to the organizer. 
  • Clinic sign-up will be handled by your team, however WE will provide the registration sign-up forms. 
  • Once a participant is registered, the pharmacy staff will contact them to complete the registration process. 
  • We require a 30-minute break to be built into the schedule for clinics lasting longer than 4 hours.

Walk-ins are welcome, but vaccines are not guaranteed for walk-in clients. They may also be subject to a longer wait time or may be limited to attending the clinics at the END of the event day. 
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FOR YOUR INFORMATION: Insurance for Immunizations
Organization *
Address (Location of Clinic) *
Contact Person - If this person will not be present the day of the clinic, a day-of-event point person must be assigned. Their name and contact information must be sent to pharmacy staff ASAP.  *
Contact Phone *
Contact Email *
Alternate Contact Person: Name, Phone Number, Email
Estimated Number of Participants *
Preferred Days of the Week. Check all that apply. *
Required
Is your facility able to provide any of the following? Check all that apply. *
Required
Vaccines Requested (Subject to Availability - Select all the apply) *
Required
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