School and Local Business 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.
School / Company Name
Date
Company Representative
Representative Position
Company Address
Company Phone Number
Representative Email
Insurance Type (company provided) some patients may still use personal private policy's
Estimated Employee's Receiving the Flu Shot (Minimum of 10 Per Day)
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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