Provider Contact Information Form
This form is to be filled out once by each medical provider’s office to designate a point of contact. This individual should be responsible to be reached if additional doses of the COVID-19 vaccine should become available, likely on short notice. The point of contact should prepare, manage, and upkeep an authorized categorization of office patients eligible to receive the vaccine at the current time, per Government mandate.
Office Name *
Assigned Point of Contact Name *
Contact phone number (Includes during/after business hours and weekends) *
Office Contact’s Primary Email *
Provider’s Office Address *
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