Flu Shot Express :: Signup now and save $20.00

Finally a Flu Shot for EVERYONE!

Welcome to the Flu Shot Express
A service of
The Washington State Flu Shot Co.

Please fill out this form as completely as possible to reserve a seat on the Flu Shot Express! Click here for information on upcoming departure times, or call 1-206-579-8840 for more information.


	First Name
	Middle Name
	Last Name
	Address
	Address 2
	City
	State
	Zip Code
	Phone
	Cell Phone
	Email
	Gender	Male Female
	Date of Birth
	Vaccine Type	Flu Pneumonia Both
	Number in your Party
	Is anyone in your party disabled?	Yes No
	Please give us details about how members of your party are disabled so we may provide accomodations.
	Use this space for any other pertinant details or questions
	List the names of the other members of your party here, excluding yourself.
	Please tell us who referred you or how you found us

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Flu Shot Express is a service of
The Washington State Flu Shot Co.