* VACCINE CLINIC (General Interest)

Hello Community Partner!

Thank you for choosing Good Day Pharmacy for a vaccination clinic!

We would love to partner with you and come on-site so that you, your staff, and your residents can stay healthy and remain protected this season.

There are no fees for us to visit you on-site for a vaccination clinic.

Please complete the form below. We need one form for each physical address.
Type of Business

Assisted Living / Memory Care CommunityEmployer (Vaccines for your employees/staff)Independent Living CommunityOther
Name of Community or Business*
Please complete a separate form for each community location.
Point of Contact Name*

First NameLast Name
Point of Contact Phone Number*
Point of Contact Email*
example@example.com
Community or Business Address*

Street Address

Street Address Line 2

CityState
ON-SITE VACCINE CLINIC
Flu vaccine clinic?*

YESNO
Number of residents / staff needing the 'STANDARD' Flu Vaccine (under age 65)? *
Number of residents / staff needing the 'HIGH DOSE' Flu Vaccine (over age 65)? *
Covid-19 bivalent booster vaccine clinic?*

YESNO
Number of residents / staff needing PFIZER Vaccine? *
Number of residents / staff needing MODERNA Vaccine?*
Shingles (Zostavax) or Pneumonia Clinic?*

YESNO
Number of residents / staff needing the Shingles (Zostavax) vaccine? *
Number of residents / staff needing the Pneumonia vaccine? *
General Comments / Questions
THANK YOU

Our Special Care Team will be in contact with you.
Should be Empty:

ON-SITE VACCINE CLINIC