Close Get Latest Internet Explorer Get Latest Firefox Get Latest Chrome

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
*
Street address
Street address 2
*
City
State
*
Zip
*
Phone
Alt. Phone
Fax
*
Email
*
Contact Person
Title

Participants

Total Number of People  in Your Group
Estimated Number of Participants (If you have fewer than 30 participants, call us at 703-698-2424.) 

 

REQUEST A DATE AND TIME (Inova Community Flu Shot Clinics run from September 2014 through February 2015

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

Parking

Is free or validated parking available for our nurses?
If no, is your location within walking distance of Metro?
If yes, which metro station:
Additional Comments