Community and Public Flu Shot Clinic Request

This form is to reserve a clinic in which the individuals will be self-pay. PLEASE NOTE: Completion of this form is not binding. We will use the information provided to schedule your clinic based on availability. Once we receive your form, we will contact you within 3-5 business days to confirm. Fluad Adjuvanted may be available upon request while supplies last.

Name of Organization*

Point of Contact

Name*

First and Last

Phone Number*

(000-000-0000)

Email Address*

Street Address*

City*

State of Event*

Select or enter value

Zip*

Secondary Contact Name*

Secondary Contact Email Address*

Expected Participation*

How many people will be vaccinated?

Check this box if any potential participants are 65 years old or over

First Choice Clinic Date*

Second Choice Clinic Date*

Third Choice Clinic Date*

Preferred Clinic Time*

Select or enter value

Additional Information

Inova Well is a proud provider of not only the Quadrivalent flu vaccine, but also Fluad Adjuvanted (designed for those over 65 years of age). Please let us know in the notes/comments field if you are interested in specialty flu vaccines or if there is anything that you would like us to know about your clinic.

Notes/Comments

Send me a copy of my responses

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