Mobile Vaccination Clinic Request Form
- The Commonwealth is pleased to offer Massachusetts organizations the option to easily vaccinate groups. Mobile vaccination services are available for employers, schools, community organizations, priority populations, and other groups. Please visit our webpage for additional information and resources: https://www.mass.gov/info-details/covid-19-mobile-vaccination-program

- If you are interested in hosting a mobile vaccination clinic in your community, please fill out the following form.

- If you are looking for an in-home vaccination, you can call the In-Home Vaccination Central Intake Line at (833) 983-0485. Representatives are available Monday through Friday from 9 a.m. to 5 p.m.. Representatives are available in both English and Spanish, and also have access to translators for over 100 languages.

- Please note that filling out this form does not guarantee the availability of a mobile clinic. We will work with you to arrange a clinic that meets your community’s needs, as possible.

- No ID or insurance will be required for vaccination. Clinics will offer the choice of the Pfizer and J&J vaccines. Vaccines will be free to all.

- Minors 12-17 may receive vaccination with appropriate consent. Please review the Massachusetts COVID-19 Vaccine Consent Form: https://www.mass.gov/lists/ma-consent-forms-for-people-under-18-years-of-age
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Your Name *
Your Email *
Your Phone Number *
Requesting Organization Name *
Your Role at Requesting Organization *
Type of Organization *
Intended population / audience for clinic: *
Requesting Organization City *
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