Susquehanna Health Flu Order Form
Customer
Company Name
Address
City
State
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WI
WV
WY
Zip
Email Address
Phone
Contact Name
Bill To
Same as Customer Info
Bill To Name
Address
City
State
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WI
WV
WY
Zip
Scheduling
Date and Time
(First Choice)
Date and Time
(Second Choice)
Would you prefer us to schedule a date and time?
Special Scheduling Notes:
Number of Employees to Receive Flu Shots
Employees X $24.00/shot =
.00
Authorization and Special Notes
Authorized By
Special Notes
or Billing Requirements: