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Request to Become a COVID-19 Service Provider

What services would you like to provide?

Screening

Testing

Anti-Virals/Medication

Safety Kit Distribution

Vaccinations

Other

Open to *

All Ages

Children

Adults

Seniors

Other

What high-risk or under-served groups are largely represented in your practice? *

Seniors

African-Americans

Hispanics

Chronically Ill (eg. asthma, diabetes, heart disease, hypertension, COPD)

Provider Contact's Information

First Name *

Middle Initial

Last Name *

Professional License *

Title *

Office Phone Number *

Mobile Phone Number *

Email Address *

County / Jurisdiction *

Practice Information

NPI Number *

License Number *

State of Issue *

Date of Issue *

Medical Specialty *

Practice Type *

Mobile Phone Number *

Email Address *

Name *

Address *

City *

State *

Zip Code *

Office Phone Number *

Back-Up Contact Information

Name *

Office Phone Number *

Email Adress *

Mobile Phone Number *

Do you currently provide vaccinations? *

Yes No

Are you a Vaccines for Children (VFC) or AVAP Provider? *

Yes No

What make and model refrigerator do you have? *

I do not have a refrigerator

What make and model freezer do you have? *

I do not have a freezer

What make and model data logger/refrigerator thermometer do you have? *

I do not have a refrigerator thermometer

Additional Information

Please provide any additional information you would like to share about your interest or relevant experience.

Cancel

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