ONSITE FLU SHOT CLINIC SCHEDULING

KMM provides onsite flu shot clinics as a company-paid program. NO INSURANCE FILING / USAGE. Minimum participation requirement is 10 employees guaranteed. Can be scheduled with a Health & Wellness Fair or separately.

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FLU SHOT CLINIC SCHEDULING

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Company: *

Billing Address: *

Zip Code: *

E-mail address: *

Contact Person: *

Requested Date for Flu Shot Clinic (Include DAY): *

Requested Time Frame: *

Address of Where Flu Shot Clinic Will Be Held: *

Location Within Company Where Flu Shot Clinic Will Be Held: (Conference Room, Break Room?) *

Phone Number *

Guaranteed 10 employee min. PER location: $38 per flu shot

11-50 employees PER location: $37 per flu shot

51-and up employees PER location: $36 per flu shot

Individual (employee paid/employee's family member): $42 per flu shot

Please let us know if you would like On-Line Scheduling or Direct with Company: *

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I herby agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time. I am authorizing KMM to provide our company with a Flu Shot Clinic for its' employees / members and have reviewed and understand cost. I understand that all employees will have to sign a release waiver showing they are requesting to have a flu shot. In addition, employees have read and understand the flu shot vaccination consent form releasing all liability to include the Company, KMM, and Administer. Payment is due after clinic unless arrangements have been made with KMM. Payment option is on-line or company check. I understand minimums must be met or a $99 travel fee will be charged. I understand no additional discounts apply.

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