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2008 Flu Shot Pre-Book Reservation

To pre-book your 2008 Flu Shot simply complete this form and submit. Upon receipt of your deposit ($10.00) you will be sent a confirmation number. All confirmations will be sent to your e-mail address of record. If you cannot attend any of the listed clinics you may apply your deposit to next years Flu Shot pre-book or request a refund. Refunds will be made within 30 days of request less a $5.00 administration fee. Payments may be made check or money order.
 
First name
      		 Last name

Street address


City
State
      		 Zip code
Primary telephone
(   )  ext.:        
Secondary telephone (Optional)
(   )  ext.: 

Date of Birth
           Year

Important: A valid email address is required to complete registration.

Email address
Examples: myname@yahoo.com, myname@example.com, etc.


Are you a previous customer?
Yes
No
Note: One reservation form per customer is necessary.


Preferred Clinic Date
      		 Preferred Clinic Location
Click Here to view the locations and dates.


Form of Payment ($10.00 Deposit):
  Check   Money Order


All clinic dates are subject to cancellation or rescheduling due to manufacturers delivery schedules and availability of supply.

All correspondence is conducted by e-mail or U.S. Mail exclusively.

No calls to clinic site facilities. 		SARA Services
3251 Bagnell Dam Blvd. Ste. 123
Lake Ozark, MO. 65049-9745

sara_services@yahoo.com

Important Information: You will need a copy of this form with your confirmation number at the time of your immunization and a photo I.D. to confirm your name.

Full payment is due at the time of your immunization minus your deposit.

Payment may be cash or personal check only.

You will receive a receipt which most Insurance Plans will honor for reimbursement if your plan covers Flu Shots.
We do not bill Insurance Plans directly.

If you are unable to attend any of the scheduled clinics in your area we will refund your deposit within thirty (30) days of notice minus a $5.00 administration fee.

Clinic Schedules are subject to cancellation or change depending on manufacturers delivery schedules, vaccine availability and government regulations.

If we cannot reschedule a cancelled clinic in your area within sixty (60) days of your original preferred date we will refund your full deposit within thirty (30) days of notice from you.


Questions:







 
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