2024 Flu Clinic Request Form

2024 Flu Clinic Request Form

Please fill out this form to submit a request for an onsite flu clinic.
Flu Clinic Pricing

Click Here for pricing details within the D.C. Metro area.

*If you are outside of D.C., Maryland, and Virgina please email Info@LifeWorkStrategies.com
Terms and Conditions:
- The earliest request date for the 2024 flu season is September 16th.
- Requests should be submitted four (4) weeks prior to the requested clinic date.
- To provide confirmation in a timely manner, we ask that you provide three (3) potential dates and times for your clinic. One of the three (3) dates provided will be confirmed.
- There is a 2 hour minimum for the duration of the requested clinic.
- There is a 30 vaccination minimum.
- Once your clinic has been staffed, you will receive an email, confirming the date, time and staff for your flu clinic.
- Date or time changes that occur within two weeks of the confirmed clinic date, will be subject to a $250 fee. Cancellation terms and fees are outlined in the program services agreement.
Company Information
Company Name*
Address for Requested Clinic*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Point of Contact Name*
Point of Contact Phone Number *
Point of Contact Email *
Is your Billing Contact different than the Point of Contact provided above?*

YesNo
Billing Contact Name *
Billing Contact Email *
Requested Clinic Information

Please provide (3) three potential dates and times for your requested clinic. We will work to fufill your request based on the order they are provided below.
1st Request Date *

MonthDayYear
Date
Time of Requested Clinic*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
2nd Request Date *

MonthDayYear
Date
Time of Requested Clinic*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
3rd Request Date *

MonthDayYear
Date
Time of Requested Clinic*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Estimated Number of Preservative Free Vaccine*
This vaccine is for anyone 6 months and older. This includes women who are nursing and/or pregnant or people with an allergy to Thimerosal.
Estimated Number of High Dose Vaccine*
This vaccine is recommended for people 65 years or older.
Estimated Number of Egg Free Vaccine*
This vaccine is for individuals that have a severe egg allergy. Limited Availability due to current CDC recommendations. https://www.cdc.gov/flu/prevent/egg-allergies.htm
Additional Information
Is your flu clinic part of a larger event such as a health fair?*

YesNo
Are any of the participants at your clinic under the age of 18?*

YesNo
Method of Payment*

Company PayIndividual Self-Pay
Do you have any parking and/or security information specific to the clinic location?*

YesNo
Parking Information
Please provide information regarding parking for the day of the clinic.
Building Security Information
Please provide any instructions for staff coming onsite.
Event Day Contact
If different from the company contact, please list the name and number of the onsite contact.
Additional Notes
Should be Empty: