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 Phone:
Fax:
Number of employees at location:
Approximate number to receive shots:
*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) Self Pay ($30 - cash or check payable to VNA) Voucher
Payment Instructions:
Preferred Month for Clinic:
Preferred Date for Clinic:
Preferred Start Time for Clinic:
Preferred End Time for Clinic:
Alternate Date/Time:
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:

Services