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Fight the Flu: Worksite Clinic Request Form

Yes, I am interested in having Inova come to my worksite to provide flu vaccinations.

Please complete the form below and include up to three date preferences for a flu shot clinic at your location. Once complete, click "Submit" at the bottom. We will respond to your request as soon as possible. Please note: the dates you request in this form are requests only and will not be confirmed until you are contacted by Inova's "Fight the Flu" office staff.

This year, Inova will also offer the new quadrivalent flu vaccine at a charge of $32 per person, in addition to the standard flu vaccine for $25 per person. Please check the box below if you are interested in more information about quadrivalent influenza vaccine.

For more information about Inova's workplace flu clinics, call 703-698-2424 or email us at flu@inova.org. Thank you for allowing Inova the opportunity to protect your employees from the flu this season.

  
Yes, I am interested in more information on quadrivalent influenza vaccine.
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I understand the charge for the standard flu vaccine is $25 per person, with a 30-participant or $750 minimum. Any clinic with fewer than 30 participants will  be charged $750.

1. Contact Information

Industry
*
Company name:
*
Street address
Street address 2
*
City
State
*
Zip
*
Phone
Alt. Phone
Fax
*
Email
*
Contact Person
Title
*
Payment Method


2. Billing Information

Name (only if different from Contact Information)
*
Street Address
Street Address 2
City
State
Zip

3. Parking

Is free/validated parking available for our nurses?
Is your worksite within walking distance of Metro?
If yes, which metro station:

 

Participants

Total Number of Employees

 
Estimated Number of Participants

 

Request up to 3 dates/times between September 1, 2014 and December 31, 2014

*
First choice
(enter day and date)
Time:
*
Second choice
(enter day and date)
Time:
*
Third choice
(enter day and date)
Time:
Additional Comments