Beacon Health System Form Site | Request an Onsite Flu Clinic

Name of Company:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is your company's billing address the same?*

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Did we do flu shots for your company last year?*

Total Number of Eligible Employees*

Which days of the week work best? (Select all that apply)*

Do you have multiple shifts? (Select all that apply)

Name of Contact Person*

Phone Number*

Email:*