HealthFax Immunization Request Form

2011/12 flu strains are:

A/California (H1N1)
A/Perth (H3N2)
B/Brisbane

"I wanted you to know that I have already received very positive comments on your management style and professionalism in handling the operation."
R.J. Zullo, M.D.
Merck & Co., Inc.

* Indicates a required field.

*Company/Client Name	A value is required.
*Contact Person	A value is required.
*Phone Number	A value is required.
Fax Number
*Address	A value is required.
*City	A value is required.
*E-mail Address	A value is required.
Number of Employees
# of Shots Given Last year (if known)
1st Date Choice
2nd Date Choice
Preferred Time	From: To:
Minimum # of Shots
Price per shot (See fee schedule)
Other services that you may be interested in.
Who would be paying for the cost of the shots?

Billing Information:
*Name	A value is required.
*Phone Number	A value is required.
*Email Address	A value is required.
Comments:

2011/12 flu strains are:

Pricing information - Immunization program
Our services and fees

Back to Immunization Page

2011/12 flu strains are:

Pricing information - Immunization program Our services and fees

Back to Immunization Page

Pricing information - Immunization program
Our services and fees