Flu Clinic Registration 2018-2019
Thank you for your interest in LifeWork Strategies' Flu Program. Please complete the webform below. If you would like to schedule a clinic at more than one location, please contact email@example.com with details for each location.
Please enter the full company name you would like to appear on your contract.
Please enter the date on or after September 24, 2018 on which you would like your clinic to take place.
Should your requested date not be available, please enter additional dates that will work for your company.
Please enter your desired start time.
Please enter your desired end time.
Please enter the address where the clinic will take place.
Please enter the name of the main point of contact.
Contact Phone Number
Please enter the telephone number of the main point of contact.
Contact Email Address
Please enter the email address of the main point of contact.
Please enter a contact name and email address for billing purposes.
Please enter the number of employees estimated to attend the flu shot clinic.
Please enter the number of Quadrivalent doses you would like at your clinic.
(Recommended for majority of the population)
Preservative Free Vaccine
Please enter the number of preservative free doses you would like at your clinic.
(Recommended for expecting mothers and those with thimerosal allergy. Does not contain thimerosal)
High Dose Vaccine
Please enter the number of high dose vaccines you would like at your clinic.
(Recommended for those age 65 and older)
Method of Payment
Method of Payment if "Other"
How did you hear about us?
LifeWork Strategies Website
Referred from another company
Please enter any parking information that may be helpful to your nurse on the day of your clinic.
Building Security Information
Please enter any additional security information.
Event Day Contact
If different from Company Contact, please enter contact information for the event date.
Send me a copy of my responses
Your submission is being processed. Please do not close this browser window until complete.