Public health departments and healthcare organizations running mobile vaccination clinics need to register patients, schedule appointments across multiple pop-up locations, and collect medical history before clinic day. Without clear location information and appointment booking, patients may miss their scheduled clinic or arrive at the wrong site.
The Mobile Vaccination Clinic Registration Form Template from WPForms helps organizers collect patient details, schedule vaccination appointments, display clinic locations on an interactive map with location selection, and gather medical information in one form.
Exploring the Mobile Vaccination Clinic Registration Form Template
This template works for public health departments, hospitals, pharmacies, community health centers, or any organization coordinating mobile vaccination programs across multiple sites. Here’s what’s included:
- Patient Name (First + Last): Captures the patient’s full name for appointment records and vaccination card documentation.
- Email Address: Provides a contact point for sending appointment confirmations, clinic reminders, or location updates if a site changes.
- Phone Number: Gives organizers a direct line for day-of coordination, rescheduling needs, or last-minute clinic notifications.
- Home Address (Address Line 1, Address Line 2, City, State, Zip Code): Collects full mailing address for patient records, service area verification, and follow-up correspondence.
- Preferred Clinic Date and Time (Date + Time): Lets patients pick their preferred vaccination appointment so organizers can manage capacity and staffing at each clinic site.
- Vaccine Requested (Dropdown): Allows patients to indicate which vaccine they need (Influenza (Flu), COVID-19, or other vaccines your clinic offers).
- Additional Notes (Allergies, accommodations, questions) (Paragraph Text): Captures important medical information like allergies to vaccine components, mobility accommodations needed, or questions for clinic staff.
- Choose Clinic Location (Map Field): Displays multiple mobile vaccination clinic sites on an interactive map with radio button selection so patients can pick the most convenient location.
Customizing the Map Experience (Geolocation Addon + Map Field)
The Choose Clinic Location field uses the Map Field to display multiple mobile clinic sites and let patients select their preferred location, which requires WPForms Pro or higher and the Geolocation Addon configured.
Without a valid Google Maps or Mapbox API key, the map won’t render and address autocomplete won’t function. This template is pre-configured with Allow Location Selection enabled, which means:
- Multiple locations required: You must add 2+ clinic sites using the repeater tool. Each location supports a unique Location Name, Address (with autocomplete via Google Places or Mapbox Search), and Marker.
- Show List of Locations is automatically enabled when you turn on Allow Location Selection, displaying location names and addresses beneath the map with radio buttons for patient selection.
- Zoom behavior: Because this template uses multiple locations, the map auto-fits all markers into view and the zoom dropdown becomes disabled.
Additional Customization Options
- Custom markers: Use the Icon Library with color picker for a branded look or upload a custom marker image (useful for distinguishing mobile clinic vans from permanent clinic sites or highlighting ADA-accessible entrances).
- Cleaner map controls: If you want a simpler “pick a clinic” display, you can hide fullscreen, map type, street view, camera control, zoom buttons, or disable dragging and mouse zooming to limit interactions.
- Nearby bias (optional): “Find Nearby Location” can be enabled to use browser geolocation and bias autocomplete results toward the patient’s area, helping patients identify which clinic stop is closest to their home or workplace.
Ready to Register Patients Across Multiple Vaccination Sites?
Use this template to collect appointments, medical information, and let patients choose their preferred mobile clinic location on an interactive map. Get WPForms Pro to access the Map field and Geolocation Addon, then customize the appointment slots and clinic sites for your vaccination program.
