Occ-Med Flu Shot Scheduling
Please fill out this form as best you can so we can provide you with the most relevant service for you and your employee.
Company Name
Date
Company Representative Contact
Representative Position
Company Address
P.O Number Required
Yes
No
Company Phone Number
Company Fax Number
Company Email
Services Requested? (Check all that apply)
Flu Shots On-Site with YMH Tech
Flu Shots at Bridge City Clinic
Flu Shots at Beaumont Clinic
Flu Shots at Baytown Clinic
Flu Shot Vaccine Order Only Company Nurse will Administer
Number of flu shots you will be ordering
Will this be a one-day campaign or multiple days? (If so how many days)
Please give three tentative dates and times. (A sales representative will reach out for scheduling)
Other questions, comments, or concerns.
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