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Health and Fitness | Vaccination Event Request

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If you are interested in requesting a vaccination service or receiving a quote please take a moment to complete the form below.

If you have any questions, please do not hesitate to call 914-684-6064.

If you are a returning client, you must login with your User Name and Password before completing the request form or your request will not go through. If you cannot remember your user name or password click here.

Person Submitting Request

First Name*

Last Name*

Title*

E-mail*

Company*

Phone Number*

Fax Number

Website URL

Address*

City*

State*

Zip*

Are you an insurance broker?

Do you work for a health insurance provider (i.e. UnitedHealthCare, Oxford Health Plans, Emblem Health,...)?

Company Being Served

Company*

Phone Number*

Fax Number

Website URL

Address*

City*

State*

Zip*

Contact's First Name*

Contact's Last Name*

Contact's E-mail*

Do not contact client directly, run all communication through me.

Who is the primary health care provider?

If other, please specify your provider?

Is the event location the same as the submitter's address?

Who is responsible for payment?

Submitter
Company being served
Third party

Third Party Details

Company*

Address*

City*

State*

Zip*

Contact's First Name*

Contact's Last Name*

Phone Number*

Contact's E-mail*

Vaccinations Desired

Flu Shots (Preservative Free)
Flu Shots (Standard)
Pneumonia Shots

Flu Shots (Preservative Free)

Number of shots desired

Flu Shots (Standard)

Number of shots desired

Pneumonia Shots

Please review Pneumonia shot protocols.

Number of shots desired

Participation

Expected Participation (if known)

Past Participation (if known)

Total Number of Employees Eligible to Attend Event