Workplace Flu Shots

Name of Organization *

Contact Name *

Phone *

Email *

Fax Number

Note: Clinics are typically scheduled mid to late September through November. December dates available upon request. The duration of your clinic is dependent on the number of anticipated participants and may change if that number changes.

Total number of employees or people invited to clinic *

(We realize everyone does not participate.)

Number of flu shots given last year:

Company Insurance Plan(s):

Will company pay for employees' immunizations:

Yes

No

Pay Portion

If paying a portion, what is the amount?

If Company will pay for all or part of immunizations, please check one of the following:

Invoice will be paid at the time of the clinic.

Payment will be mailed to St. Barnabas Medical Center after clinic is completed.

Will employees pay for their own immunization(s)

Yes

No

Pay Portion

If paying a portion, what is the amount?

Note: If yes, cash or check payment is due at time of service.

Employee family members will be invited to participate in flu clinic:

Yes

No

Pay Portion

If yes, will family members pay for their own immunization(s) (Amount):

In order to best accommodate all of your employees/community please state your preferences below:

Day of the week that works for us:

Time of day works for us:

Morning

Afternoon

Evening

Please indicate if specific date(s) and time(s) are required

(due to shift work, multiple locations, Company wide meetings, health fair, etc.)

We are never too busy for your referrals. For more information or to schedule, please contact Michele Snyder at 724-443-7231 or msnyder@stbarnabashealthsystem.com

reCAPTCHA

724-443-0700

Flu Shot Clinics

Convenient Walk-In Flu Shots

at the St. Barnabas Medical Center

Hours: Monday – Friday 8:30 am – 4:30 pm

Please print this consent form and bring it with you:

Schedule A Workplace Flu Shot Clinic

Workplace Flu Shot Clinic Scheduling Form

Contact

724-443-0700

Flu Shot Clinics

Convenient Walk-In Flu Shots

at the St. Barnabas Medical Center

Hours: Monday – Friday 8:30 am – 4:30 pm

Please print this consent form and bring it with you: <img class="alignleft size-full wp-image-8233" src="https://stbarnabashealthsystem.com/wp-content/uploads/2013/12/Form-large-button.png" alt="Download Form" width="200" height="25">

Schedule A Workplace Flu Shot Clinic

Workplace Flu Shot Clinic Scheduling Form

Contact

Please print this consent form and bring it with you: