Flu Clinic Registration

How to register:

Complete the Flu Clinic Registration Form below. We will contact you to confirm a specific date and time and we will send you materials to help you prepare for your clinic.

After we have confirmed a specific date and time, all that remains is for you to encourage your group or employees to attend the on-site clinic.

Flu Clinic Registration Form

Please check off at least two options for preferred days and times for a clinic.*

Please note, you will:

Require a minimum of 15 participants (remember family, friends, and neighboring business are welcome to attend).
Be responsible for promoting the clinic to members of your organization (we will provide materials to assist you with this).
Clinic location should have:
  - Easy accesibility for all
  - Adequate lighting 
  - Areas for registration and form completion
  - A table and several chairs
  - Ideally, a room or area with entrance and exit for smooth flow

Should you require more information, please contact Katie at (603) 224-4093, ext. 5815 or e-mail katherine.quinn@crvna.org

Clinic Information:

Payment options

How will you pay for the immunizations? We have several payment option to choose from. They include:

Direct bill to your office or company
Employee payment at time of clinic
Employee Insurance coverage
  - Anthem
  - Harvard Pilgrim
  - Medicaid
  - Medicare Advantage
  - Medicare Part B
  - Tufts

Dates to hold the clinic

You probably do not want to hold clinics on days that employees are likely to be off.
Do you want to tie the clinic into an onsite meeting, when more people are likely to attend?

Number of people

Do you have the minimum number of people? (If not, you may be able to combine your clinic with a neighboring business or organization).
Do you have an approximate idea of the maximum number who may attend?

Questions

Include all questions, special requests, or concerns you may have on the registration form.

Insurance Plans

All participants must bring their insurance cards to the clinic.