New Entity COVID VAX Clinic Info
Information auto-enters into New Entity VAX Site Spreadsheet
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Entity Name *
Entity Type *
Point of Contact *
Phone Number *
email *
Address *
Zip Code *
County *
Registered in Immunet? *
MDPCP or Application ID Number:  Please enter the last 4 digits of your MDPCP ID or Application ID number: (e.g., for "MDPCP-1234" or "T1MD-1234, please enter "1234.")
Capacity - Number of vaccinations you can administer each week
Hours of Operation
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