Flu Shot Clinic Agreement Form

2011 Flu Reservation
Minimum 20 Doses
Call for 2011 Special Pricing

Pricing includes all vaccine, nursing services, and supplies
Onsite clinic scheduled at your choice of date, time, and location.
Delivery of vaccine to your location on/before clinic date
Local nurse at your location
Online flu shot scheduling tool
No canceled clinics because of vaccine shortage
Timely, professional administration of flu shots
Free promotional materials

2011 Terms

OccuVAX will be accepting checks onsite or credit card pre-payment online. No cash will be accepted at clinics.
Changes to orders are only accepted in writing, either via email or fax. No exceptions. Changes should be emailed to flusupport@occuvax.com or faxed to 402-593-9638. Please make sure contact name and information is included.
Nurses will be provided based on a formula of 1 hour per 24 shots ordered at each clinic and pro-rated as required. If additional nursing time is needed or if business requests the nurse(s) to remain longer than the allotted hour(s), based on the ordered number of doses, business agrees to be billed at the rate of $50 per scheduled hour at each clinic.
Business agrees to pay a $50 cancellation fee for any clinic canceled 10 or fewer days before the scheduled clinic date.
Confirmation is required for the number of doses being sent prior to shipping from the OccuVAX warehouse. The OccuVAX website will send out dose confirmation reminders 2 weeks, 1 week and 3 days before your supplies are shipped. A reply to these confirmations is required. If confirmation is not received, OccuVAX reserves the right to reschedule the clinic. Business acknowledges that the online scheduling tool on the OccuVAX website will close to new sign ups 7 days before the scheduled date of your clinic.
Delivery - Business agrees to accept delivery of all vaccine and supplies prior to the clinic. Business agrees to refrigerate and care for vaccine (as required) until clinic begins.
Return Policy – Immediately after clinic, business agrees to return paperwork, Epi-pen, and Blood Pressure Cuff w/Stethoscope and any leftover vaccine with the return label and box provided. If paperwork and outlined supplies are not returned within 7 days of completion of the clinic, business will be invoiced an additional $100 supply cost. If vaccine is leftover after the clinic, it should be returned to OccuVAX for destruction and a credit will be given down to $10 per dose after clinic minimum has been met.
Billing - Business guarantees full payment for all confirmed doses with a minimum of 20 doses at each individual clinic run by OccuVAX on behalf of your company.
Authorized Signature - An authorized agent of the business must complete, sign, and return this terms page in order for the clinic to be scheduled with OccuVAX.

Payment Terms – Payment is due within 30 days from date of invoice. A late charge of 1.5% per month will be charged on past due amounts

Please check box to confirm all terms have been read and understood