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

Pharmacies | Pharmacy Registration

This flu season, Protect Someone Else, When You Protect Yourself

General Information

Pharmacy Information

Name of Pharmacy

Address

City

State

Zip Code

Phone

Website

Facebook

Twitter

Are you a Mutual Drug Member?
YesNo

Primary Contact Information:

Preferred Title

First Name

Last Name

Phone Number

Email*

This will be used as our primary means of contact with the pharmacy.

Additional Forms

Detailed Clinic Profile

Local Media
Information


Please complete the forms above and send them to:

info@vaccineambassadors.org

Tell Us About Your Pharmacy

  1. Number of Pharmacy Staff:

    Pharmacists Other Staff

  2. Which of the following immunizations does your pharmacy provide?

  3. If you selected "Other," please list the additional immunizations your pharmacy provides below:

  4. How many prescriptions do you fill a day?

The following quotes will be used to describe your pharmacy:

  1. Please provide 3-5 printable quotes on why you chose to become a Vaccine Ambassador and why this program is important to your pharmacy and community.

  2. What sets your pharmacy apart from other pharmacies in the area?

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