Flu Clinic Request for 2014
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Thanks very much, and we apologize for any inconvenience.
Contact Name: |
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Address of Clinic:
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E-mail
Phone Number: |
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Number of Employees Participating in the Seasonal Flu Clinic: | |||
Preferred Month:
October November December January
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Preferred Day of the Week: Monday Tuesday Wednesday Thursday Friday |
Preferred Time: Morning Afternoon Full Day |
Special Instructions (Directions, Parking, Security, etc.): |
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Yes, I would be interested in hearing more about the FluMist® product and how it can benefit my employees. |
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Yes, I would be interested in opening up our company Flu Clinic to employee families. |
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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: