Workplace Wellness Inquiry
When received, we will contact you with more information.
Workplace information
Company Name
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Point of Contact
First Name
Last Name
Position
Email
example@example.com
Phone Number
Please enter a valid phone number.
Wellness Program Interest
Our company is interested in the following:
Flu Shot Clinic/Other Vaccination Clinic
Health Screening (blood pressure, blood glucose, etc)
Weight Loss Program
Insurance Advisement (Corporate Pharmacy Benefit Management OR Assistance with New to Medicare Transitions)
Other
I would like the following vaccines to be offered at our vaccine clinic:
Flu (ages 3-64)
High Dose Flu (65+)
COVID booster
RSV Vaccine
Shingles
Pneumonia
Tetanus
Other/Unsure
Method of payment:
Please bill our insurance for each individuals vaccine
Please bill the company for all vaccines
Please bill the company for any vaccines for individuals not covered by insurance
Other
If you checked the 'other' box, please share what ideas you have to improve your workplace wellness.
Location for wellness offering:
On-site at our company
At the pharmacy
Health Fair
Other
Total number of employees:
Goal date:
Submit
Should be Empty: