Event Request - TotalWellness

Please complete the form below to request your onsite tetanus vaccination event. After submitting your request, a TotalWellness representative will reach out to you to confirm event details.
Which type of Tetanus vaccine would you like to offer at your event?*
- Tdap (Tetanus, Diphtheria, and Pertussis)
- Td (Tetanus and Diphtheria)
How many shots would you like to order?*
What date works best for your event? Remember to select a date at least 4 weeks from today.*
MM slash DD slash YYYY
Please also provide an alternate date for your event, in case your first selected date is not available.
MM slash DD slash YYYY
What time would you like your event to start? We will determine your event end time based on the number of shots ordered, assuming one nurse can administer up to 20 shots per hour.*

: Hours

Minutes

AM/PM
Please provide the location for the event.*
Street Address Address Line 2 City State ZIP Code
Please provide the event room name, if available.
Please select one option for scheduling participant appointments.*
- Online appointment scheduling tool
- Paper signup sheet
Please provide any specific parking, driving and/or security information our staff should be aware of.
In order to contact you regarding your event request, we will need your contact information.
Name*
First Last
Email*
Phone*
Please include any additional requests or comments below.