Influenza Clinic for Businesses - Sign-up Form

Company Name:
Address:
City:
State:	Zip:
Contact Name:
Phone:
Email:
Estimated number of staff participating in the Vaccine Clinic:
Requested Date:
Time:
Cost paid for by employer employee
	Influenza vaccine $30.00 per employee Pneumococcal vaccine $40.00 per employee

You will receive a confirmation by phone or e-mail.

How to encourage staff to get vaccinated against influenza:

• Advertise through email and posters
• Send emails calling for staff to book a specific time slot for the vaccination rather than having random attendance times
• Post information sheets about the vaccine and the flu
• Invite family members to attend clinic
• Provide a small incentive to staff who get vaccinated - Snooze and Cruise, chocolate