Order Form On-Site Flu Shots

Complete the form below to order your flu shot event.

Company Name*

Address of Flu Shot Event*

Address Line 1 Address Line 2 City State ZIP Code

Flu Shot

Quantity of Flu Shots – $35.00 per shot*

Small Site Fee*

Price:

Since you are ordering less than 40 shots, there is an additional $250 small site fee.

Total

$0.00

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Number of Flu Shots Ordered

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Number of Flu Shots Ordered

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Number of Flu Shots Ordered

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Number of Flu Shots Ordered

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Number of Flu Shots Ordered

Requested Event Date*

Please select your preferred date for flu shot event. We require at least 30 days notice. Please note that we start on-site flu events after September 1.

Requested Event Time*

Your order includes two hours of event time.

Requested Event Time*

Your order includes two and a half hours of event time.

Requested Event Time*

Your order includes three hours of event time.

Requested Event Time*

Your order includes three and a half hours of event time.

Requested Event Time*

Your order includes four hours of event time.

Requested Event Time*

Your order includes five hours of event time.

Requested Event Time*

Your order includes four and a half hours of event time.

Would you like to use our participant online appointment scheduling tool?*

Please include location security, parking, and driving instructions.

Contact Information

Are you the overall company contact and the day of event site contact?*

Name*

First Last

Email*

Phone*

Site Contact Information

Site Contact Name*

First Last

Site Contact Email*

Site Contact Phone*

Important Points

Please check the box next to each statement indicating that you understand and agree to the policy.

Charges for Additional Shots Administered & Extra Nurse Time*

The credit card provided will be charged for the total event cost. If more shots are administered than the number ordered, TotalWellness will invoice the company for the additional shots at $35.00 per shot. If the nurse is requested to stay past the event end time, TotalWellness will charge for the additional time at $85 per hour, per nurse.

Change Fees*

You may increase the number of shots ordered, adjust the event time or change the event location within the same metro area within 14 days of the event for no fee, 11-13 days prior to the event for a $75 fee, and 10 or fewer days prior to the event for a $150 fee. Decreases to event order numbers are not allowed. Event dates cannot be changed once confirmed without a fee.

Cancellation and Rescheduling Fees*

Once confirmed, cancelling or rescheduling your event will incur a minimum $75 fee. Cancellations or reschedules requested 14 – 30 days prior to the event days will incur a $150 fee, requests submitted 8 – 13 days prior to the event will incur a $300 fee and requests submitted 7 or fewer days prior to the event will incur a $500 fee.

Age Policy*

TotalWellness does not vaccinate children. All participants must be a legal adult in the state where the shots are being administered.

Payment

Credit Card

Agreement Terms

Terms of Service*

You must scroll through the entire terms of service before agreeing to the terms.

I agree to the Terms of Service

Signature*

Date Signed*

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TotalWellness Account Executive

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TotalWellness Account Executive

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TotalWellness Account Executive

Flu Shot Order Form 2024-2025

Contact Information

Site Contact Information

Important Points

Payment

Agreement Terms