Thank you for selecting VNA as your flu immunization provider.  To schedule a clinic, please complete this form click submit.  You can also fax to Andrea Witt, Flu Prevention Coordinator at (402) 930-4077.  Once the request is received, our coordinator will contact you.

Your Name:
Your Email Address:	Used for email delivery purposes only.
Subject:
Date:
Organization Name:
Address:
City:
State:
Zip:
Phone Number:
Preferred Month:	October November December
Preferred Day:	Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Preferred Time:	8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm
Number of clinics needed:
Number of employees:
Number of shots flu vaccinations expected:
Will you invite family members/others to attend?	Yes  No
Additional Information