Pre-Registration for Hospital / Pharmacy

Required *

Directions

Facilities with multiple locations should submit a separate pre-registration form for EACH vaccination SITE (rather than licensed provider), unless otherwise approved. Fields with red asterisks are required. You are encouraged to print a copy of this completed form before its submission. Hit the "Submit" button to finish pre-registration.

Site Information

Name of Site being Pre-Registered: *

Street Address: *
Physical street number and name for the site being pre-registered. (e.g., 108 Lee Street)

Street Address Line #2
Include additional needed information, e.g., Suite 300, Room 400 West.

City:*

State:*

Zip/Postal Code: *

Name of the Person who is the H1N1
Point of Contact (POC) for the Site: *

First Name Last Name

Phone Number for Site's POC: *
Provide the full ten digit number with area code, e.g., 304-344-5243.

Fax Number for Site's POC: *
Provide the full ten digit number with area code, e.g., 304-348-6821.

E-mail Address for Site's POC: *

Thank You!

By selecting submit, I attest that the information provided, is to the best of my knowledge accurate.

To finish the pre-registration process , hit "Submit" at the bottom after you have completed this form.