Group Flu Shot Sign-Up

Individuals requesting flu clinic services: Please click here to sign up for our flu clinic.Businesses or groups requesting flu clinic services: Please fill out the form below to submit your flu clinic request.

Requesting For *

Testing Site Location *

Business Name *

Business Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Number of Participants *

Preferred Testing Day *

Preferred Testing Time *

Contact Name *

First Name Last Name

Phone Number *

Area Code Phone Number

E-mail *

Please schedule this group for on-site flu shots Please have a representative contact us about onsite flu shots

Once submitted, please print out one of the forms on the following page, fill it out and bring it with you during your flu shot appointment.

Enter the message as it's shown *