Flu Clinic Request Form
Within 2 business days of filling out this request form, Moose Pharmacy will contact you to go over details and availability. If you need to get in contact with Moose Pharmacy staff sooner, please contact us at (704) 436-9613 or e-mail kiera@moosepharmacy.com
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Has your site done a flu clinic with Moose Pharmacy before?
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Estimated number of people interested in getting the flu shot *
Please specify the number of people wanting the regular flu shot or the high dose. The high dose is only indicated for those aged 65 and above.
What time of day works best for your site? *
Required
What date would work best for you? *
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Please provide a back-up date that would work best for you *
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Site name and address
Your name *
Phone number *
E-mail
Preferred contact method *
Required
Questions and comments
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