IMMUNIZATION PROGRAM | CLINIC REQUEST FORM

Please select if this request is for a Standard On-Site Flu Clinic or Senior Facility On-Site Flu Clinic:

Standard On-Site Clinic Examples: Businesses, Churches, Schools, Senior Centers
Senior Facility On-Site Clinic Examples: Assisted Living, Skilled Nursing, Independent Senior Facility


Note: You will recieve a confirmation email once your request is submitted. If you do not, please contact MC VNA: 1-800-852-1232