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 Egg-Free Vaccines *

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

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

Billing Option *

Employer Billed (Minimum of 30 vaccines)
Insurance Billed (Minimum of 20 vaccines))

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.

Start/End Date for Vouchers

Start Date *

End Date *

Verification *