Please use this form to request a flu shot clinic at your company site Organization Name*Street Address*City*Zip Code*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPoint of Contact name* First Last Point of Contact Telephone*Point of Contact Email Address* Enter Email Confirm Email Estimated number of quadrivalent flu shot participants*Please enter a number from 0 to 1000.Estimated number of high-dose flu shot participants*Please enter a number from 0 to 1000.Check here if no day preference No preference Preferred day of week for programMondayTuesdayWednesdayThursdayFridayAlternative day of week for programMondayTuesdayWednesdayThursdayFridayCheck here if no time preference No preference Preferred time of day for program : HH MM AM PM Alternative time of day for program : HH MM AM PM Other CommentsSubmitted by* First Last IMPORTANT:Appointment requests should be limited to non-emergency communications. In case of emergency, call 911 or go to the nearest emergency room. Please confirm with "Acceptance" and complete the "captcha" field below and push Submit.Acceptance* I agree to the Terms and Conditions CAPTCHA
