Flu or Covid-19 Clinic Request Form

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 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 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* .
.
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)MorningAfternoonAfter 6PM
Please give some possible Dates
Should be Empty: