Flu or Covid-19 Clinic Request Form
Within 1 business day of filling out this request form, Soleil Pharmacy will contact you to go over details and availability. If you need to contact staff sooner, please contact us at (443) 281-9157 Or mail firstname.lastname@example.org
Please enter a valid phone number.
Name of Facility
Address of Facility
Street Address Line 2
State / Province
Postal / Zip Code
Which vaccination Clinic are you interested in?
Has your site done a flu clinic with Soleil Pharmacy before?
Estimated number of people interested in getting the flu shot.
Please specify the number of people wanting the high dose. The high dose is only indicated for those aged 65 and above.
What time of the day work bests for your site?
Early morning (before 8am)
Please give some possible Dates
Should be Empty: