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Fight the Flu: Community Flu Shot Clinic Request Form
Fight the Flu: Community Flu Shot Clinic Request Form
Yes, I am interested in scheduling Inova HealthSource to offer a flu shot clinic for my group. I understand that the cost for the vaccine is $30 per participant and Medicare Part B is the only insurance accepted.
Please fill out and submit the form below, requesting the day and date you prefer for your flu shot clinic.
This date is a request 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 community.
Contact Information
*
Group Name:
Type of Organization
---Select One--
Faith-based
Library
Recreational center/gym
Senior site (non-residential)
Senior site(residential)
Other
*
Street address
Street address 2
*
City
State
---Select One--
VA
DC
MD (Montgomery & P.G. only)
*
Zip
*
Phone
Alt. Phone
Fax
*
Email
*
Contact Person
Title
Participants
Total Number of People in Your Group
---Select One--
30-50
51-75
76-99
100-199
200-299
300+
Estimated Number of Participants
(If you have fewer than 30 participants, call us at
703-698-2424
.)
---Select One--
30-50
51-75
76-99
100-199
200-299
300+
REQUEST A DATE AND TIME (Inova Community Flu Shot Clinics run from September 2013 through February 2014)
*
First choice
(enter day and date)
Time:
---Select One--
5:00 a.m.
5:30 a.m.
6:00 a.m.
6:30 a.m.
7:00 a.m.
7:30 a.m.
8:00 a.m.
8:30 a.m.
9:00 a.m.
9:30 a.m.
10:00 a.m.
10:30 a.m.
11:00 a.m.
11:30 a.m.
12:00 p.m.
12:30 p.m.
1:00 p.m.
1:30 p.m.
2:00 p.m.
2:30 p.m.
3:00 p.m.
3:30 p.m.
4:00 p.m.
4:30 p.m.
5:00 p.m.
5:30 p.m.
6:00 p.m.
6:30 p.m.
7:00 p.m.
7:30 p.m.
8:00 p.m.
*
Second choice
(enter day and date)
Time:
---Select One--
5:00 a.m.
5:30 a.m.
6:00 a.m.
6:30 a.m.
7:00 a.m.
7:30 a.m.
8:00 a.m.
8:30 a.m.
9:00 a.m.
9:30 a.m.
10:00 a.m.
10:30 a.m.
11:00 a.m.
11:30 a.m.
12:00 p.m.
12:30 p.m.
1:00 p.m.
1:30 p.m.
2:00 p.m.
2:30 p.m.
3:00 p.m.
3:30 p.m.
4:00 p.m.
4:30 p.m.
5:00 p.m.
5:30 p.m.
6:00 p.m.
6:30 p.m.
7:00 p.m.
7:30 p.m.
8:00 p.m.
Parking
Is free or validated parking available for our nurses?
Yes
No
If no, is your location within walking distance of Metro?
Yes
No
If yes, which metro station:
Additional Comments
SUBMIT
