Flu Clinic Request for 2014


We are currently experiencing technical difficulties with our online form. Please contact aprildetzler@bradyandassociates.ca for your request.

 

Thanks very much, and we apologize for any inconvenience.


Company Name:

Contact Name:

Address of Clinic:


Postal Code:

E-mail

Phone Number:
Number of Employees Participating in the Seasonal Flu Clinic:

Preferred Month:

 

October

November

December

January

 

 

 

 

 

 

Preferred Day of the Week:

Monday

Tuesday

Wednesday

Thursday

Friday

Preferred Time:

Morning

Afternoon

Full Day

Special Instructions (Directions, Parking, Security, etc.):

 

 Yes, I would be interested in hearing more about the FluMist® product and how it can benefit my employees.

 Yes, I would be interested in opening up our company Flu Clinic to employee families.

 Yes, I would be interested in having a second follow-up clinic for any employees who can not attend the first clinic.



Submit your form: