Senior Housing Flu Shot Scheduling -Your Medical Home

Senior Housing 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 / Location Name

Date of services requested

Company Contact Name

Company Position

Company Address

Company Phone Number

Company Email

Estimated Residents Receiving the Flu Shot Over 65 Years Old (Minimum of 10 Per Day)

Estimated Residents Receiving the Flu Shot Under 65 Years Old (Minimum of 10 Per Day)

Please give three tentative dates and times. (A sales representative will reach out for scheduling)