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2010/2011 H1N1/Seasonal Immunization Registration

To register for your immunization simply complete this form and submit.

 
First name
      		 Last name

Street address


City
State
      		 Zip code
Primary telephone
(   )  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 registration form per customer is necessary.


Immunizations preferred
H1N1
Seasonal




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




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

Primary Contact - 636 751-1080.

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 receive a return email which is your confirmation of immunization request and must me presented at the clinic.

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.

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


Questions:







 
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