Booster Clinics Pharmacy Partnerships

LeadingAge is working with GeriMed, an association of 1300 independent pharmacies in every state except New Hampshire and Delaware, to connect pharmacies to settings in need of on-site booster shot clinics. Filling out this form does not guarantee you’ll be matched with a pharmacy for an onsite clinic and nor does it mean you must partner with any pharmacy you are matched with. This effort is an attempt to introduce aging services providers to pharmacies.

1. Onsite contact Information

	First name
	Last name
	Phone number
	Email address

2. Provider/ Organization Information
Approximate

	Name of the Organization
	Approximate number of residents and staff onsite who will receive a vaccine through an onsite clinic?
	Physical street address
	City
	State
	Zip code

Provider type (pick all that apply):