SERVICE AGREEMENT
This form constitutes a Service Agreement between above named Company and the Seattle Visiting Nurse Association (SVNA) to provide a 2012, on-site, workplace, seasonal "Flu Immunization Clinic".
SVNA will provide licensed, Registered Nurses (RNs) for flu shot administration; all administrative staff needed to support immunizations; immunization supplies; and, patient consent forms. SVNA will maintain the security and privacy of
identifiable health information as required by law.
Company agrees to provide appropriate space for immunization clinic and to assist in promoting the Flu Immunization Program to it's employees.
SVNA is a non-profit, tax-exempt, 501(c)(3) community based, immunization and wellness services provider.
SVNA does not require Company to guarantee, assure or otherwise commit to any minimum Flu Clinic participation. However, we do ask, and appreciate Company efforts to promote and support the event to it's employees to achieve at least 20 immunizations per clinic.
SVNA does not charge any travel or other clinic administration fees. SVNA does not assess clinic cancellation fees.
PAYMENT OPTIONS (Please select all options that apply)
2012 FLU CLINIC REQUEST FORM - BUSINESS
COMPANY INFORMATION
Company Address
Billing Address
City
Zip
Zip
City
Company Contact
Phone
Email Address
FAX
PLEASE REVIEW FORM ... WHEN READY TO SEND CLICK SUBMIT BUTTON
Preferred Month
Preferred Day
Preferred Time
Special Requests/ Comments
State
State
(IF DIFFERENT THAN COMPANY ADDRESS)
Company Name
Parking Validation
Estimated Number of Individuals to Receive Immunizations
SVNA will invoice Company.
(Please select Plan)
If "Other" insurance please describe.
(Please describe)
NOTE: If you selected "OTHER" or have more than one Company Insurance Plan please use "Other" box below to describe or identify additional coverage(s).
