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Immunization Clinic Service Agreement

To schedule your clinic, please
PRINT OUT this form,
COMPLETE the information
FAX to 248.967.8315

 IMMUNIZATION 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