EPIC Immunization Request Form

Please provide us with the following information to ensure necessary arrangements (training team, delivering of materials, etc.) are made. Our office will contact you as soon as possible to confirm the date of your presentation.

Thank you and we look forward to providing you with this educational opportunity.

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* 1. Select which program (s) your office would prefer below:

Childhood Program (Birth - 18yrs.) - 1.5 hrs.

Childhood Program - short version - 1.0 hr.

Adolescent Program (9 - 18yrs.) - 1.25 hrs.

Adult Program (19yrs. - Senior) - 1.5 hrs.

Combo Program (Birth - Senior) - 1.75 hrs.

Coding Program for Childhood Immunizations - 1.25 hrs.

Women's Health Program (OB/GYN practices) - 1.5 hrs.

Healthcare Professionals in Training (Schools) - 1.5 hrs

Improving HPV Rates in Your Practice - 1.0 hr.

Vaccine Hesitancy - 1.0 hr

COVID-19 Program - 1.0hr. NEW!

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* 2. Who is requesting this program?

Name & Title:

Email Address: (required)

Practice/Organization:

Practice Address:

Contact Number:

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* 3. Which presentation option is best for your practice?

Option A - Live Webinar Presentation - A zoom meeting will be set up on the date and time selected by your practice.

Option B - Pre-scheduled Webinar Presentation - Dates for each EPIC curriculum will be pre-scheduled and sent to your practice to register. Start time is usually 12:30 pm. (Maximum of 10 practices can sign up for each webinar)

Option C - Pre-recorded Webinar Presentation - Your practice can request access to an archived webinar to view individually at your own convenience or during office hours at various times.

EPIC Immunization Request Form

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* 1. Select which program (s) your office would prefer below:

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* 2. Who is requesting this program?

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* 3. Which presentation option is best for your practice?

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* 4. What dates/times work best for your practice?

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* 5. How did you find out about our programs?