COVID-19 Vaccination Clinic Request Form

COVID-19 Vaccination Clinic Request Form
Thank you for your interest in becoming a COVID-19 vaccine provider. Please be informed that completing this form does not guarantee access to the COVID-19 vaccine.
Facility Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Name of Contact Person
First NameLast Name
Do you have affiliation with any healthcare system provider
YesNo
Healthcare System Provider*
Number of Patient Records
Number of patients served
Should be Empty: