Home: Health Solutions: Worksite Flu Shot: Flu Shot Registration Form

Flu Form Company Information Company Name: HealthPartners Group Number: Are you Fully Insured Self-Insured Main Phone Number: Fax Number: Mailing Address: (City, State, Zip Code) Company Contact Information Contact's Name: Direct Phone Number: Email Address: Program Information Program and Payment Options: Include only HealthPartners covered employees Include HealthPartners covered employees and covered dependants Do you have a preferred HealthPartners flu vendor: Yes No If yes, indicate your preferred HealthPartners flu vendor: Indicate in which language(s) you'd like to receive the CDC information sheets: English Spanish Other If other, specify: Location Specific Information Number of location(s): Location #1: HealthPartners Group#: Estimated number of shots: Location #2: HealthPartners Group # Estimated number of shots: Location #3: HealthPartners Group #: Estimated number of shots: Location #4: HealthPartners Group #: Estimated number of shots: Location #5: HealthPartners Group #: Estimated number of shots: We look forward to working with you. If we can answer any questions, please call (952) 883-7574. You can also fax the printable version to (952) 853-8732.