On-Site Vaccine Clinic

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On-Site Vaccine Clinic

On-Site Clinic Information & Terms

Any local business or organization interested in scheduling an on-site clinic for their employees through ApotheCARE Pharmacy must complete this online form. A trained pharmacist and certified technician will administer vaccines at your worksite, saving employees time and trips. To continue providing this service free of charge, a minimum of 20 participants is required for scheduling an on-site clinic appointment. Businesses or organizations with fewer than 20 participants will be required to pay a clinic fee of $100.

Business Information /Point of Contact

* Indicates required field

Company Name: *

Address: *

City / State / Zip: *

Contact Name (First/Last): *

Contact Phone Number & Extension: *

Contact Job Title: *

Contact Email Address: *

Preferred Contact Method: *

Email Phone Call

Insurance/Payment

The information in the next section can be found on your Employee Pharmacy Insurance Card. Most vaccines are covered by insurance as they are considered a preventative measure.

Employee Pharmacy Insurance Provider *

Member ID: *

RXPCN: *

RXBIN: *

RXGRP: *

If an employee does not have company or personal insurance, the employee can pay at the time of vaccination by cash or check. We can also directly bill the company if you are wanting to pay on the employee's behalf.

Vaccination Information

Please select which vaccinations you are interested in - please note that options with a * may require verification before administering to confirm insurance coverage or patient immunization records:

Vaccine Options *

Influenza (Flu) Influenza (Flu) HD 65+ COVID-19 Shingrix * (Shingles Two Dose) RSV * (Respiratory Syncytial Virus) Pneumococcal * (Pneumonia) HPV * (Human Papillomavirus) Tdap * (Whooping Cough)

Select all that you are interested in!

Clinic Scheduling

On-site clinics are scheduled Monday through Friday in one hour increments per 20 patients for the month of September & October. If you need a specific time or longer than an hour, please include in the additional info section. It is recommended to include an alternate clinic date & time in the event your preferred is not available.

Preferred Clinic Date & Time: *

Alternate Clinic Date & Time: *

Estimated Number of Employees: *

A minimum of 20 is required

Additional Info: *

Anything else we should know about your request?

Vaccine Clinic Coordinator

Our Vaccine Clinic Coordinator will review your submitted form and reach out to confirm your clinic booking and finalize any details. You will also be sent our Vaccine Consent Form (PDF) that all employees receiving a vaccine will be required to complete and provide to our staff on the day of the clinic along with a copy of their pharmacy insurance card.

Submit

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