On-site COVID-19 Testing Clinic

On-Site Workplace Flu & COVID-19 Vaccine Clinic Inquiry

This form is for workplace clinics. Once we receive the filled form, we will contact you shortly to confirm availability.
Business Name*
Point of Contact Full Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Estimated Number of Individuals Needing Vaccinations*
Preferred Day of Week - 1st Choice*
Preferred Day of Week - 2nd Choice*
Preferred Time of Day*
Are you interested in on-site COVID-19 vaccinations?*
Which COVID-19 vaccines are you interested in?

ModernaPfizer
Comments?
Should be Empty:

On-Site Workplace Flu & COVID-19 Vaccine Clinic Inquiry