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    Request a Flu Shot Clinic


    To request a flu shot clinic at your workplace, please complete the following informational form. A clinic coordinator will contact you to discuss the details. Or, you can contact a flu shot coordinator by phone.

    I am interested in offering:  

    Flu shots
    Pneumonia vaccine
    Community wellness programs
    I am in the following county:  
    Company name:  
    Contact name:  
    Phone number:  
    E-mail address:  
    Street address:  
    City:  
    State:  
    Zip Code:  
    Number of employees:  
    Preferred dates:  
    Additional information: