Participation

Flu Clinic Type *

On-site Clinic at Employer Location
Vouchers Redeemable at WellSpan Occupational Health

Contact Information

Employer Name *

Contact Name *

Contact Phone *

Contact Email *

Billing Address (Street, City, State, Zip) *

Onsite Clinic Locations

Onsite Location Address 2

Onsite Location Address 4

Onsite Location Address 6

Onsite Location Address 8

Onsite Location Address 10

Onsite Location Address

Onsite Location Address 3

Onsite Location Address 5

Onsite Location Address 7

Onsite Location Address 9

Pre-Order Commitment

Number of Standard Dose Vaccines (ages 9 and older) *

Number of High Dose Vaccines (ages 65 and older) *

Would you like privacy screens? *

Yes
No

Do you need registration/check-in staffing? *

Yes
No

Preferred Date of Clinic

Vaccine clinics are available September 25th - November 3rd
Date and time will be confirmed at a later date and is dependent upon vaccine supply and staffing schedules.

Backup Date/Time Info

Start/End Date for Vouchers

Start Date *

End Date *

Onsite vaccine clinics are available September 2024 through December 2024. Following submission of this form, a Wellness Product Support Specialist will email you to confirm your clinic date, time, and requested doses. The Specialist will also share an onsite clinic marketing toolkit, setup guide, checklist, and voucher, if applicable.

Verification *