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Primary Health Request Form
Hello Partners. We are using this form to gauge how your agency plans on using Primary Health for COVID-19 vaccination clinics.
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* Indicates required question
Site Name
*
Your answer
Primary Local Administrator
*
Your answer
Primary Local Email
*
Your answer
Primary Local Phone
*
Your answer
Back-up Local Administrator
Your answer
Back-up Local Email
Your answer
Back-up Local Phone number
Your answer
Scheduling clinics only
Scheduling clinics and immunization reporting
*
Your answer
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This form was created inside of State.co.us Executive Branch.
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