Jim Myer's Drug- Tuscaloosa, AL

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South

Towers

Alberta

Capstone

HEALTH & WELLNESS

Employer Flu Vaccine Clinic

Name of Business

Date

Your Address:

Your Phone:
*Area code required

Your Fax:

Your Email:

Your Zip Code:

Contact Person:

Approximate Number of Employees That Would Participate:

Will employee family members be allowed to participate?
Yes
No

Please check at least one below

Will the employer cover the cost of the vaccine for the employee?
Yes
No

Will the employer cover part of the cost of the vaccine?
Yes
No

Will the employee be responsible for the full cost of the vaccine?
Yes
No

Comments/Questions