Flu Shot Scheduling

View the latest information on the H1N1 Flu (Swine Flu)

Electronically: To schedule flu shots, please fill out the form below.
(Fields in bold are required.)

Contact Information Company Name Address City State ZIP Contact Name: Phone (e.g.: 314-555-1212) Fax Email Number of employees to receive shot: Approx. total # of company employees: Hours of operation:

Requested Dates and Times

Date - ex. 5/30/2005
Start Time Requested - ex. 11:00 AM
End Time Requested - ex. 1:00 PM
Please note: 40 shots per hour per nurse

First Preference Requested Date Start Time End Time Second Preference Requested Date Start Time End Time Third Preference Requested Date Start Time End Time