Immunization Clinic Reservation Form

Flu or Covid-19 Clinic 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 thuy@soleilpharmacy.com
First Name*
Last Name*
Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid cell phone number so that we can contact the person in charge of the clinic the day of the vaccination clinic.
Email*
example@example.com.
Name of Facility*
Address of Facility*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has your site done a flu clinic with Soleil Pharmacy before?*

YesNo
Which vaccination Clinic are you interested in?*

FluCovid-19BothPneumoniaShingles
Estimated number of people interested in getting the influenza vaccines # flu* .
Estimated number of people interested in getting the HIGH dose influenza vaccines (the High dose is only indicated for those aged 65 and above).
#High Dose
Estimated number of people interested in getting the Covid Boosters vaccines   # Covid*   .
Estimated number of people interested in getting the shingles vaccines   # Shingles*   .
Estimated number of people interested in getting the pneumonia vaccines   # Pneumonia*   .
.
How many vaccination clinics would you like to set up?   Number*

Please give your 1st vaccination clinic date   Date* , Time   Timeframe*     .
Please give your 2nd vaccination clinic date   Date#2 , Time  Timeframe#2
Please give you 3rd vaccination clinic date   Date#3  , TimeTimeframe #3
What time of the day work bests for your site?*

Early morning (before 8am)MorningAfternoonAfter 6PM
How many volunteers do you plan on having on the day of the clinic?*
Will there be free parking?*
Will a private room be available for patients who request privacy for their vaccination?*
Would you like to have User access to Soleil portal to get up-to-date information on the clinic?

YesNo
Which email should be used to create a user account?
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Flu or Covid-19 Clinic Request Form