Reaching beyond the walls of our clinic to bring a healthy start to every child.

Clinics | Clinic Application

Apply To Become a Vaccine Ambassador Clinic

Simply fill out the form below and a member of our organization will contact you shortly about how together, we can make your clinic a Vaccine Ambassadors Clinic.

General Information

Primary Clinic Site

Name of Practice

Address

City

State

Zip Code

Phone

Email

Add More Locations

Additional Site #1

Name of Practice (If Different)

Address

City

State

Zip Code

Phone

Email

Additional Site #2

Name of Practice (If Different)

Address

City

State

Zip Code

Phone

Email

Tell Us About Your Practice

  1. Year Established:

  2. Is Your Clinic Located in an Urban or a Rural Area?

    UrbanRural

  3. Number of Providers:

    MD NP PA

  4. Type of Practice:

    PediatricFamily MedicineOB/GYN

    Other:

  5. Number of Current Patients:

  6. Average Number of Patients per Year:

  7. Average Number of Patients per Day:

  8. Age Break Down Estimate (% of Total Patients):

    <5yrs 6-12yrs >12yrs

  9. Does Your Practice Have a Newborn Recruitment Process?

    YesNo

  10. If yes, please explain:

  11. Estimated Payment Method Breakdown (% of Total Patients):

    Cash Credit Card Check Insured Medicaid Uninsured

Individual Contact Information

Primary Contact

Name

Preferred Title

Address

City

State

Zip Code

Phone

Email

Practice Manager

Name

Preferred Title

Address

City

State

Zip Code

Phone

Email

Why Do You Want To Be A Vaccine Ambassadors Clinic?

Please Briefly Describe:

  1. Why is your practice interested in participating in the program?

  2. What your goals are in regards to implementing this program in your practice?

  3. How we can best assist your clinic to have a successful program?