Emergency Medicine Event Staffing

GW-MFA OnSite Flu Shot Clinic Request Form

Note: Required fields are marked with an asterisk (*)

Company/Point of Contact Information

Company Name *

Unless otherwise specified please use only letters, spaces, commas, hyphens, and periods in all fields.

First Name *

Last Name *

Phone Number *

Please use the "202-555-1234" format.

E-Mail *

We will never sell or disclose your email address to anyone.

Clinic Info

Estimated number of recipients *

(a minimum of 10 are required for onsite visit), please use a number eg. "10" or a range "10-20"

Requested Date for Clinic *

(not final date, gives us a approximate time frame to work from), please use the "MM/DD/YYYY" if the calendar fails to appear.

How did you learn about us

If Referred by:

Image Verification *

GW-MFA Pricing $25/shot, no insurance is accepted.

All requests received before May 31, 2009 will receive $25 credit on the final flu shot invoice or $50 credit on the purchase of an

Automated External Defibrillator through our GW Lifesaver Program!

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