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 Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Estimated Number of Individuals Needing Vaccinations
*
Please Select
Less than 10
10-20
20-30
30-40
40-50
More than 50
Preferred Day of Week - 1st Choice
*
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Day of Week - 2nd Choice
*
Please Select
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Time of Day
*
Please Select
Morning (9am-11am)
Early Afternoon (12pm-2pm)
Late Afternoon (2pm-4pm)
Are you interested in on-site COVID-19 vaccinations?
*
Please Select
Yes
No
Which COVID-19 vaccines are you interested in?
Moderna
Pfizer
Comments?
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