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St. Luke's Health Solutions

Flu Shot Clinic Registration Form

If you have any questions or would prefer to register by phone, please call (208) 381-7831

Company Profile
Company :
*
Company Contact:
*
Position/ Title :
*
E-mail address :

*

Mailing Address :

*

Address Line 2 :

City :

*

State :

*

Zip :

*

Phone :
 *
Fax: :

*
   
Number of Employees:
*
Number of Locations:
*
Estimated Number of Participants
(minimum of 25) :
*
Spouses / Significant Others Included:
   
Onsite Clinic Request
Preferred Month :
Preferred Day :
Preferred Time :
Payment Method :
Employer
Employee Self Pay
Spouse Self Pay
Shared Cost

* Indicates Required Fields

Comments:

We will contact you within 3 business days to verify the date and time of your clinic. Once your event is scheduled, you will receive a Confirmation of Services agreement electronically.

 


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