Flu-Busters Clinic Service Agreement

Name of Company Representative:	Today's Date:
Signature of Company Representative:	Company's Phone Number:
Company:	Number of Participants:
Address:	Company's FAX Number:
City:	For VNA Office Use Only (clinic type):
Zip Code:	Confirmed Clinic Date and Time:

To ensure staffing, fax this completed form and a map to your site to:
VNA Manager of Community Programs
FAX (248) 967-8315.

Questions? Please call (248) 967-8751 or e-mail vna@vna.org