MPV Clinic Request Form

The Washington State Department of Health (DOH) strives to keep our communities healthy. If your organization is planning a community event and would like DOH to offer Monkeypox vaccines, please complete the form below. If possible, please submit this form at least 14 days prior to your event. All services are based on availability. We will consider events occurring in less than 14 days on a case-by-case basis. To access this form in another format or language, please email marcia.via@doh.wa.gov or call 360-878-7596.

Requester Information

Type of Organization*
Phone

(if applicable)

Preferred Method of Communication*

Event Details

Please select a date that is at least two weeks away from today's date. If you would like to schedule multiple events, please submit a new form for each subsequent event.

Is your date flexible?*
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Please provide a short description of your event.

Event Location

If you are still planning your event, enter "TBD" for any details that are still to be determined.

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Please enter the number of attendees you expect to attend your event.

Please enter the number of volunteers you can provide.

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Select all that apply.

Please list all that apply

Please list all that apply

(if applicable)

Select all that apply.

Select all that apply.

Would you like to receive a link to allow individuals to pre-register for your event?*

Please select all that apply.

Acknowledgement

By clicking below, you acknowledge that although the Department of Health would like to support your request by providing the Care-a-Van to support your event:

-    Your request may be fulfilled by the local health department as part of our practice of collaboration and coordination.

-    Your request may be fulfilled by a Department of Health vaccine contractor should the Care-a-Van not be available.

-    Your request may not be fulfilled if it is submitted with less than two weeks’ notice.

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