Name of Organization*Organization Type*CorporateNon-ProfitSchoolCommunityGovernment EntityExtended Care FacilityBilling Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Contact Person*Contact Email* Contact Phone*Contact FaxAlternate Contact PersonAlternate Email Alternate PhonePlease indicate how payment will be made* Company Pay (company receives invoice after clinic) Self Pay (Cash or Check made payable to VNA Community Services) Medicare Part B (no charge; patient must present card at time of vaccination) Payment InstructionsAre you interested in other immunization services? Tdap (tetanus, diphtheria, pertussis - whooping cough) Pneumonia Shingles TB Skin Tests Wellness Screenings Other Other, please specify# of Clinics to Schedule*123Clinic Site #1Clinic Address* Use billing address? Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of people at locationApproximate number to receive immunizations*Preferred Clinic Date* Date Format: MM slash DD slash YYYY Start Time* : HH MM AM PM End Time* : HH MM AM PM Alternate Date/TimeAlternate Clinic Date Date Format: MM slash DD slash YYYY Start Time : HH MM AM PM End Time : HH MM AM PM Parking instructionsClinic location within buildingComments/QuestionsWould you like to schedule an additional on-site clinic?YesNoAdditional clinic siteClinic location Use billing address? City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of people at locationApproximate number to receive shots*Preferred Clinic Date* Date Format: MM slash DD slash YYYY Start Time* : HH MM AM PM End Time* : HH MM AM PM Alternate Clinic Date Date Format: MM slash DD slash YYYY Start Time : HH MM AM PM End Time : HH MM AM PM Parking instructionsClinic location within buildingAdditional notes (optional)CommentsThis field is for validation purposes and should be left unchanged.
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