Corporate Flu Clinic Request

Thank you for your dedication towards preventing the flu! Please complete the information below to help us schedule a date and time for your flu clinic. Please note that 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. The Enhanced flu shot (65+) may be available upon request while supplies last.

Name of Organization*

Organization Size*

How many employees does your organization have?

Your Contact Information

Name*

First Name and Last Name

Phone Number*

(000-000-0000)

Email Address*

Street Address*

Additional Address Information

Please provide additional information if applicable. Suite Number, Floor, Room of Clinic, etc.

City*

State*

Select or enter value

Zip*

Secondary Contact Name*

Secondary Contact Email Address*

I agree to:*

Be billed at the rate of $40 per trivalent flu shot for the 2025-2026 flu season. I also understand that I will be billed at a minimum of 80% of my expected participants. Example: Expected participation is 30 people. I am committing to payment for at least 80% or 24 shots. Please check the box upon agreement:

Clinic Details

Expected Participation*

Please note you must have at least 30 participants.

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

First Choice Clinic Date*

The date must be between 9/1/2025 - 3/31/2026

Second Choice Clinic Date*

The date must be between 9/1/2025 - 3/31/2026

Third Choice Clinic Date*

The date must be between 9/1/2025 - 3/31/2026

Preferred Clinic Time*

Select or enter value

Additional Information

Inova Well is a proud provider of not only the trivalent flu vaccine, but also Enhanced flu shot (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

Check this box if you are interested in booking other health fair services to go alongside your flu clinic. An Inova Well representative will be sure to reach out to you with more information.

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