2024 Flu & Covid-19 Booster Clinic Request Form

2024 Flu & Covid-19 Booster Clinic Request Form
Name of Organization*
Entity Type*
Company Street Address*
Please provide the address where your clinic will be held, if this differs from your company's address.
City*
State
Zip Code*
Contact Name*

First NameLast Name
Contact Phone*

Area CodePhone Number
Contact Email*
Fall 2024 Covid-19 Booster Update: We are planning to offer Covid-19 Boosters at our on-site clinics this fall. We are awaiting the fall 2024 FDA & CDC Covid-19 Booster recommendations. If you are interested in offering Covid-19 Boosters at your fall 2024 vaccination clinic, please select the second option below.
Please Select the Vaccination Types your Organization is Interested in:*

Flu VaccineFlu Vaccine & Covid-19 Booster Vaccine
Please note we are unable to bill Cigna.
Health Insurance Plan*
If your organization offers multiple insurance plans, please select 'MULTIPLE'.
Multiple Health Plan(s)
If "MULTIPLE" was selected above, please list your health plan(s).
What Percentage of your Workforce do you Expect to be in-office this Fall?*
Roughly how many Employees do you expect to participate in the clinic? *
Based on the percentage you listed in your previous answer.
Preferred Month for Clinic?*
Please Select your organization's Preferred Clinic Days. (Limit 3)*

MondayTuesdayWednesdayThursdayFriday
Parking Validation?*
Can you provide parking validation to our nurses?
Parking Instructions
Special Requests / Comments
SERVICE AGREEMENT

This form constitutes a Service Agreement between above named Company and VaxPoint LLC d/b/a Seattle Visiting Nurse Association (SVNA) to provide a seasonal on-site "Flu and/or Covid-19 Booster Immunization Clinic" at your specified location.

SVNA will provide licensed nurses for flu shot and/or Covid-19 Booster administration, administrative support, immunization supplies, and a digital registration link. SVNA will maintain the security and privacy of identifiable health information as required by law.

Company agrees to provide appropriate space for immunization clinic and to assist in promoting the Flu and/or Covid-19 Booster Immunization Program to its employees.

Company efforts to promote and support maximum employee participation will be appreciated.

SVNA does not charge any travel or clinic cancellation fees.
PRICING

Our Covid-19 Booster shot pricing has not been set for Fall 2024. We are still awaiting reimbursement rates for the vaccine. Once the Covid-19 Booster rates have been set, we will alert all of our clients to our pricing.
PAYMENT OPTIONS*

Employee’s insurance plan will be billed. Uninsured employees will be billed by SVNA individually for their immunization(s).Employee’s insurance plan will be billed. The Company agrees to reimburse SVNA for uninsured employee's immunizations.The Company will pay out of pocket for all employee’s immunizations, regardless of insurance status. SVNA will invoice the company directly at $55 per flu immunization. Our 2024 Covid cash rate is still TBD based on the vaccine price. For reference, our 2023 cash rate was $200.
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2024 Flu & Covid-19 Booster Clinic Request Form

PRICING