Immunization Clinic Registration

*Organization Name:
*Address for Clinic Site:
*Billing Address:
*Billing City:
*Billing State:
*Billing Zip:
*Contact Person Name:
*Contact Phone:
*Contact Email:
Alternate Contact:
Alternate Email:
Alternate Phone:
Fax:
Number of people at location:
*Approximate number to receive shots:
*Types of Flu Vaccine:	Trivalent flu shot FluMist nasal spray Quadrivalent flu shot High dose flu shot Preservative free flu shot
*Please indicate how payment will be made:	Medicare Part B (no charge; patient must present card at time of vaccination Company Pay (company can pay after clinic or can be billed) Blue Cross or Blue Shield Self Pay ($30 - cash or check payable to VNA) Voucher
Payment Instructions:
# of Clinics:	single clinic multiple clinics
Clinic #1
Preferred Month for Clinic #1:
Preferred Date/Time for Clinic #1:	from until
Alternate Date/Time for Clinic #1:
Clinic Location for Clinic #1:
Clinic #2
Preferred Month for Clinic #2:
Preferred Date/Time for Clinic #2:	from until
Alternate Date/Time for Clinic #2:
Clinic Location for Clinic #2:
Clinic #3
Preferred Month for Clinic #3:
Preferred Date/Time for Clinic #3:	from until
Alternate Date/Time for Clinic #3:
Clinic Location for Clinic #3:
Are you interested in other immunization services?:	Tdap (tetanus, diptheria, pertussis - whooping cough) Pneumonia TB Skin Tests Wellness Screenings
Directions from a major freeway:
Parking instructions:
Entrance to building:
Location of Clinic within building:
General Comments/Questions:

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