Physicians Request Form

At The Vaccine Clinic our mission is to provide preventative care to children regardless of ability to pay. Our commitment to offering low- to no-cost vaccines to the community will continue to set us apart as we aim to increase the immunization rates and help stem the rise of vaccine-preventable diseases. As we continue to grow, so will our impact on the communities we serve.

As the backbone of the health care system, physicians are a critical part of increasing the quality and access of care to the community.

Please fill out the form below if you are interested in one of the 3 packages (View Packages).

Package Option:

*First Name:

Last Name:

Zip Code:

Daytime Phone:

Evening Phone:


*Comments / Questions


Package Option Information

Option 1 - Bronze:

  • I believe in the mission and wish to partner with The Vaccine Clinic
  • I would like to refer overflow patients (possibly without appointments, insurance, or the ability to pay) to The Vaccine Clinic
  • I would like to register parents of patients under 5 years old for free e-mail and/or text message reminders about their child's next required immunizations
  • I would like to be added to The Vaccine Clinic referral list and receive vaccine pamphlets
Option 2 - Silver:
  • All of Option 1
  • I would like to host marketing material in my clinic
  • I would like to host The Vaccine Clinic's raffle bin at my clinic
Option 3 - Gold:
  • All of Options 1 and 2
  • I would like to partner with The Vaccine Clinic to open a clinic in my area and help provide services to children in need.

NOTE: The Vaccine Clinic is not a PCP and will not become a PCP. We fax medical records to the registered PCP within 48 hours of the patient's visit.