Vaccine Clinic Intake Form

Alpha Medical Lab

Became a CMS approved Mass Vaccination Provider in 2022. We provide on-site Vaccination Services for both your Residents and Employees all year round.

Schedule Your Clinic

Vaccine Clinics for your Facility New Admit Vaccine
Scheduler In Home Vaccine Services

Alpha Medical Laboratory became a CMS approved Mass Vaccination Provider in 2022. We provide on-site Vaccination Services for both your Residents and Employees
all year round. We will update and maintain current immunization records in the Oklahoma State Immunization System (OSIIS), and provide a dedicated vaccine portal.

On-site Vaccine Services

Vaccines Available

CALL 918-561-6896
or EMAIL [email protected]
to schedule your Clinic

Want to plan your 2023 Vaccine Clinic with Alpha? Fill out this form below to plan for your 2023/2024 Vaccination Season.

If your Organization has multiple locations needing Vaccine Clinics, please fill out a Vaccine Clinic Intake Form for each location, or contact our Vaccine Coordinator at [email protected] to schedule.

Facility Information

Facility Name:

Facility Address:

Street Address City State

Number of Residents at this Facility:

Number of Employees at this Facility:

Facility Contact Information

Contact Name:

Title:

Phone Number:

Email:

Preferred Clinic Date:

Preferred Clinic Time:

*Please note, we will do our best to accommodate your requested Vaccine Clinic Date/Time. Your requested clinic date should be at least 2 weeks from today’s date to allow our Vaccination Team enough time to prepare for your Clinic.

Vaccine Procurement

Select the types of Vaccines you are needing at your Clinic

High Dose Influenza (Over 65)

Regular Dose Influenza (Under 65)

Covid-19 (Bivalent Only)

Pneumonia

Shingles

Other

High Dose Influenza (Over 65); Estimated number of Doses:

Regular Dose Influenza (Under 65); Estimated number of Doses:

Covid-19 (Bivalent Only); Estimated number of Doses:

Pneumonia; Estimated number of Doses:

Shingles; Estimated number of Doses:

Other _______ Estimated number of Doses:

Vaccine Clinic Billing Information

Select

Bill Insurance: Billed to Participant’s insurance

Direct Bill: All Vaccinations administered at Clinic will be billed to the Organization.

Direct Bill and Bill Insurance: Please Note on Participants Vaccine form which to bill.

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Start your visit

Vaccine Clinics for your Facility New Admit Vaccine
Scheduler In Home Vaccine Services

On-site Vaccine Services

Vaccines Available

CALL 918-561-6896
or EMAIL [email protected]
to schedule your Clinic