Work Site Influenza Vaccine Clinic Request Form (New)
Please complete the form below. Once we receive your submission, someone will contact you to schedule your clinic.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Company Name
*
Estimated Number Receiving Flu Shots (minimums may apply):
Would you also like to offer the updated COVID-19 vaccine at the clinic, if available?
*
Yes
No
Estimate Number Receiving COVID-19 Vaccinations (minimums may apply):
Length of Clinic
*
30 minutes (10-20 employees)
1 hour (21-40 employees)
More than 1 hour (41+ employees)
Preferred time of clinic
*
Morning
Afternoon
No preference
Address Where Clinic Will Be Held
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Were you referred by anyone?
*
Yes
No
Name of person that referred you:
*
First Name
Last Name
Business name that referred you:
*
Please add any additional notes here. If you have a specific request for your clinic date and time, please make a note here. We will do our best to accommodate your request.
Should be Empty: