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2011 Employee Flu Vaccination Program

2011 LWS Flu Program

To initiate a request for a fall 2011 Flu Clinic, please complete the form below. You will receive a reply within 24 business hours.

Fields marked with a * are required.

CLINIC INFORMATION:

Company Name:

Address:

City:

State:

Zip Code:

Contact Full Name:

Contact Phone:

Contact Email:

# of Employees at this location:

Expected number of Flu Shots:

Indicate the approximate number of participants you had last year.
If this is your first clinic, use 30% of your workforce as the estimate.

Preferred Date for your clinic: *

Select date between Sept. 12, 2011 - Dec. 20, 2011

Preferred start time of your clinic:

This is a request until confirmed by LifeWork Strategies

PLEASE ANSWER THE FOLLOWING QUESTIONS:

Do you need a clinic at another location(s)? Yes No

If yes, please call LifeWork Strategies at 301-315-3655 to make arrangements for your other locations

Is parking available at this building for the nurse/staff? Yes No

If possible, would you like your 2010 nurse to return for your 2011 clinic? Yes No No Preference

How did you learn about us?

COMPANY BILLING INFORMATION:

Billing Contact full Name:

Address:

City:

State:

Zip Code:

Phone Number:

Email Address:

Check here if you would like your invoice emailed to this email address

PAYMENT OPTIONS:

Flu Vaccination: Our company will fully cover the cost of the clinic for employees.
Our company will pay the nursing fee and applicable parking fees, and require employees to self-pay the per person rate.
Our company will require that employees fully self-pay at the rate of $25 per person. However, understand that our company is responsible for the 20 person min. if not met.

If you like to discuss another payment arrangements please call 301-315-3655.

Family Participation: Our company will invite family members, and require that family members fully self-pay for the flu vaccine.
We will not be inviting family to our worksite flu clinic.

Pneumonia Vaccination:

Would you like to offer Pneumonia vaccinations at this clinic? Yes No

Number of Pneumonia Shots?

Method of Payment for Pneumonia Vaccination Our company will pay for the Pneumonia vaccine at the rate of $55 per person (min. 5 people).
Our company will require that employees fully self-pay at the rate of $55 per person; however I understand that our company is responsible for the min. of 5 vaccinations if not met.

TDAP Vaccination:

Would you like to offer TDAP vaccinations at this clinic? Yes No

Number of TDAP Shots?

Method of Payment for TDAP Vaccination Our company will pay for the Tdap vaccine at the rate of $60 per person (min. 5 people).
Our company will require that employees fully self-pay at the rate of $60 per person; however understand that our company is responsible for the min. of 5 vaccinations if not met

Please let us know if there are any special instructions that would be helpful to the nurse in finding your location to ensure on-time arrival (30 minutes before start of your clinic)