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Fight the Flu: Worksite Clinic Request Form

Yes, I am interested in having a flu vaccination clinic brought to my worksite by Inova.

Please fill out and submit the form below, requesting up to three dates as your preferences for a flu shot clinic at your location. These dates are requests only and will not be confirmed until you are contacted by Inova's "Fight the Flu" office staff.

For more information, 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.

  
*
I understand that the charge for the flu vaccine is $25 per person and in order for Inova to cover its expenses, there is a 30-participant minimum for a clinic. Any clinics with fewer than 30 participants will  be charged $750 (the cost of 30 vaccinations).

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 (The Inova Worksite Flu Program runs from September 2012 through February 2013)

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