I herby agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time. I am authorizing KMM to provide our company with a Flu Shot Clinic for its' employees / members and have reviewed and understand cost. I understand that all employees will have to sign a release waiver showing they are requesting to have a flu shot. In addition, employees have read and understand the flu shot vaccination consent form releasing all liability to include the Company, KMM, and Administer. Payment is due after clinic unless arrangements have been made with KMM. Payment option is on-line or company check. I understand minimums must be met or a $99 travel fee will be charged. I understand no additional discounts apply.
I acknowledge and agree that the information submitted through this form may be stored electronically and used by KMM for the purpose of communicating with me and coordinating the requested flu shot clinic. I understand that I may withdraw my consent to be contacted at any time.
I authorize KMM to coordinate an on-site flu shot clinic for our employees and/or members and acknowledge that I have reviewed and understand the associated program costs and requirements.
I understand that each participant must complete and sign the required vaccination consent and release forms prior to receiving a flu shot. Participants are responsible for reviewing and acknowledging the consent documentation, including applicable releases of liability for the sponsoring organization, KMM, participating healthcare providers, and clinic personnel.
Unless otherwise arranged in writing with KMM, payment is due upon completion of the clinic. Accepted payment methods include online payment and company check.
I understand that a minimum participation requirement applies. If the minimum number of participants is not met, a $99 travel fee may be assessed. I further understand that no additional discounts or promotional offers apply unless expressly approved by KMM in writing.*
