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

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

mm/dd/yyyy

Second Choice Clinic Date

mm/dd/yyyy

Third Choice Clinic Date

mm/dd/yyyy

Preferred Clinic Time

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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