Prevention MD promotes health and wellness by providing internet medical information and classes

 

Thank you for choosing Prevention MD to provide your company or organization with flu vaccinations.  Cost for a flu vaccination is $30.  We require a minimum of 15 participants.  An additional $50.00/hr fee will be added for less than 15 participants.  To schedule your company, please provide the following information.

All fields required. Use 'n/a' for fields that do not apply.

1.  Company Name, Address, Phone, and Fax:  

         

2.  Contact Person:                    

      2a. Direct Phone Line:    

      2b. Cell/After hours Phone:    

      2c. E-mail Address: 

3.  Alternate Contact:                    

      3a. Direct Phone Line:    

      3b. Cell/After hours Phone:    

      3c. E-mail Address: 

4.  Billing Information (if different from above) Contact Name, Billing Address, Phone, and Fax:  

         

5.  Approximate number of vaccinations:

                    Flu: 

6.  Please select payment option.

                   

7.  Please specify your normal work week and hours of your work day.

            

8.  Please specify the times of any shift changes we need to cover.

            

9.  Please specify any dates, days or times that DO NOT WORK for you.

            

10.  Please specify any special instructions or comments.

            

11.  Please select payment option for nurse's parking.

                   

12.  How did you find you find out about us?

            

13.  Do you agree to the above terms?  

            Yes     No

14.  Would you be interested in information on our CPR, First Aid, AED or Travel Medicine services?  

            Yes     No

Our nurse will require a table and two chairs at the vaccination site.  To expedite service, please notify your employees as to the date and time allotted for service.  We like to take up as little of your company time as possible.

 

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