Inova HealthSource Flu Shot Program Registration

Yes, I am interested in having a flu shot program coordinated at my worksite.  I understand that the cost is $23 per participant.  A minimum of $690 will be charged for clinics that have less than 30 participants. For more information on scheduling one or more flu shot clinics at your workplace, please call 703-204-3339 or e-mail flu@inova.org.

* Indicates required field.

Contact Information
Company Name* Industry
Street Address*
City* State
Zip*
Phone* Fax
Contact Person* E-mail*
Title
Preferred Method of Contact Phone
Mail
E-mail		 Billing Info.

Street
Address

City
State

Zip Code

(Only if different from contact Information)

Participants
Total Number of Employees
 Estimated Number of Participants
Payment Method
 Employer
Employee
Co-pay

Program Date and Time

The Inova Corporate Flu Program will be held
beginning November 2006  through December 2006.
First Choice
Second Choice

Parking
Is free/validated parking available for our nurses?
Yes
No Is your worksite within walking distance of Metro?
Yes
No
If yes, which metro station:
Additional Comments
You will be contacted within 5 business days.
Thank you for allowing Inova the opportunity to keep your employees healthy.