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Germ Guy
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Germ Guy

Clinic Information Form


If you are a physician or clinic and wish to add, remove or edit your clinic to the list of locations where vaccines are administered, please fill out the information below. A representative will contact you within 5 to 7 business days to confirm your listing on Vaccines411. This form can also be accessed at any time to update your profile.

All fields marked with a * are required

 

   
 
   
 

 
Other, please specify:

* Please select all vaccines that you administer at your clinic/office.

 
Other , please specify:

* Do you have a minimum age requirement?
   
 

* Do you offer online appointment bookings?
   
 

* Do you offer on-site vaccination services to businesses, schools, homes or other locations?
*Please note that if you click yes to on-site vaccination, we will follow-up shortly by phone for more information.
   
 

Special Instructions or Notes
August 2016