Flu Shot Clinic Reservation Form

Welcome to the Clarian Arnett Health Flu Shot Clinic Online Reservation Program. Providing employee flu shots is one way to keep your company's costs down by preventing illness and lost work time during flu season. Each flu season, Clarian Arnett conducts 75-100 flu shot events for area employers committed to lowering absenteeism by keeping employers healthy. In order to efficiently process a growing number of requests for flu shot events, Clarian Arnett has developed this online registration system.

Please complete the information below and submit your request by hitting the “Send Reservation Request” button at the bottom of the page. Upon receiving your registration request, a Clarian Arnett Health representative will contact you to finalize your flu shot event.

Note: There is a limited supply of flu vaccine, thus we can only guarantee flu shots for those employers who prepay; in return, we will reduce the cost of the vaccine by 20% ($20 per flu shot instead of $25).

We look forward to serving you in 2008!

Event Location Information
Company Name: *
Address (where event will
take place):		 *
City/State/Zip: *
Onsite Coordinator: *
Coordinator Phone: *
Coordinator Fax:: *
Coordinator E-mail: *
*Denotes required field
2008 Flu Pricing

Prepay $20/ Flu Vaccine
Billed $25/ Flu Vaccine
Clinical staff time billed at $65 per hour
Mileage in excess of 25 miles (round trip) billed at .585 per mile
(see Terms below)
2008 Terms
  • Clarian Arnett Health shall provide clinical staff to administer the Flu Vaccine. One staff member can administer up to 25 vaccines per hour with informed consent forms completed in advance. The number of employees and event duration determine the need for additional medical staff.
  • Example: 50 employees/ 2 hour event/ 1 clinical staff @ $65 per hour
  • Example: 50 employees/ 1 hour event/ 2 clinical staff @ 65 per hour
  • Clinical staff time is billed at $65 per hour/one hour minimum per clinic staff.
  • The first 25 (round trip) miles included, thereafter; the employer agrees to pay .585 per mile.
  • Employer guarantees full payment for flu vaccines ordered (minimum 10 flu shots or $200 ($20/vaccine prepay), or $250 ($25/vaccine billed)) plus staff time and travel expenses.
  • Employer agrees to distribute informed consent forms to each employee prior to the event and ensure that employees present at the event with a completed informed consent form. (Note: informed consent forms will be available at each event, but onsite completion may cause event delays and additional costs at a rate of $65 per hour per clinical staff)

Event Information
Total employees at location: *
Number of flu shots requested at location (Note: employees must be 18 years of age or older): *
Number of onsite flu shot events requested (Note: 10 person minimum for onsite events): *
Will you need more than one clinic at this location?
If yes, how many locations? (10 shot minimum for each clinic)
Requested date(s)/time(s) for event(s):

If the dates and times requested are unavailable:

  
Best day of the week for your clinic: *
Best time of day for your clinic: *
*Denotes required field

To make the most of your event and to encourage participation, we will provide you with materials to help you advertise your onsite event. We will also provide you an informed consent form, which you will provide to each employee. Each employee must submit a completed consent form at the time of check in. 

Please indicate how you would like to receive promotional material and the consent form.
 
Please send  promotional materials via e-mail
Please send promotional materials via fax
 
Please provide alternative e-mail address if different from the Coordinator Email:
Please provide alternative fax number if different from the Coordinator Fax:
Business Billing Information
Please Select Prepay or Bill:
 

Companies choosing the billing option will be charged at a rate of $25 per flu vaccine ordered, plus additional staff time and travel expenses as set out in the Term (see Terms above). Please complete the information below.
 
Company Name: *
Company Address: *
City/State/Zip: *
Contact Name: *
Contact Phone Number: *
Contact Fax Number: *
Contact E-mail Address: *
* Denotes required field
Please identify any special situations or instruction that will aid the nurse in coordinating your flu shot event (location, driving or parking directions, accessibility concerns, scheduling needs). Nursing staff will plan to arrive 30 minutes in advance of the scheduled event time. Please ensure that the space designated for the event is available prior to the first scheduled vaccination.
Please click, Send Reservation Request button to complete a request.
Contact Clarian Arnett Occupational Health Services flu shot coordinator, Kim Synesael at (p) 765-448-8180 (f) 765-448-8702 or email ksynesael@clarianarnett.com with any questions.
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