Seasonal Flu Vaccination Program

Seasonal Flu

Program Features

80/20 RULE

Why offer a flu program?

Flu Facts

Service Interest Form

Please check which of the following available programs you are interested in:
Flu Vaccination Program Pulmonary Function Test Cholesterol Screening Blood Pressure Glucose Screening Audio Screening Physician Presentation Bone Densitometry Screening
Salutation *
Name *
Title
Company *
Address *
City *
State *
Zip Code *
Email *
Phone *
Phone Extension
Fax
Cell Number
How did you hear about us?

Please explain:

Program Information How many locations do you wish to schedule?

Location 1

Requested Date	Requested Time	Program Length








Click here to add additional dates. If this date is not avaliable, AP will contact you. NOTE * One nurse can administer approximately 25 shots per hour. Multiple nurses per hour are available.

Number of Employees

Number of Anticipated Participants

Division Name

CONTACT INFORMATION

Same as Above

Salutation

(if different than above)

Name

(if different than above)

Title

(if different than above)

Email

(if different than above)

Phone

(if different than above)

Phone Extension

(if different than above)

Fax

(if different than above)

Facility Address

(if different than above)

Facility City

(if different than above)

Facility State

(if different than above)

Facility Zip

(if different than above)

Location 2

Requested Date	Requested Time	Program Length








Click here to add additional dates. If this date is not avaliable, AP will contact you. NOTE * One nurse can administer approximately 25 shots per hour. Multiple nurses per hour are available.

Number of Employees

Number of Anticipated Participants

Division Name

CONTACT INFORMATION

Salutation

Name

Title

Email

Phone

Phone Extension

Fax

Facility Address *

Facility City *

Facility State *

Facility Zip *

Location 3

Requested Date	Requested Time	Program Length








Click here to add additional dates. If this date is not avaliable, AP will contact you. NOTE * One nurse can administer approximately 25 shots per hour. Multiple nurses per hour are available.

Number of Employees

Number of Anticipated Participants

Division Name

CONTACT INFORMATION

Salutation

Name

Title

Email

Phone

Phone Extension

Fax

Facility Address *

Facility City *

Facility State *

Facility Zip *

Location 4

Requested Date	Requested Time	Program Length








Click here to add additional dates. If this date is not avaliable, AP will contact you. NOTE * One nurse can administer approximately 25 shots per hour. Multiple nurses per hour are available.

Number of Employees

Number of Anticipated Participants

Division Name

CONTACT INFORMATION

Salutation

Name

Title

Email

Phone

Phone Extension

Fax

Facility Address *

Facility City *

Facility State *