Costco Flu Shot Program Form printable pdf download

Thank you for your inTeresT in The CosTCo

flu shoT Program for your emPloyees.

First, please complete the following information:

Company Name: ______________________________________________________________________________________

Estimated Number of Employees Who Will Participate: ______________________________________________________

Company Contact Person: ______________________________________________________________________________

Job Title, Department: _________________________________________________________________________________

Address: _____________________________________________________________________________________________

City: _____________________ State: _____________ ZIP: ________________ Phone: _____________________________

Email: ___________________________________________________________ Fax: _______________________________

Next, please choose an option that best fits your needs:

Option #1 – Buy Costco Cash Cards for each participating employee, preloaded to cover the cost of the flu shot.

Your employees can visit any Costco Pharmacy during the duration of the program and receive the immunization.

Option #2 – Request an on-site clinic. Invite Costco Pharmacy staff to attend and administer the immunizations

at your place of business and pay one lump sum for the immunizations that are administered (a minimum of 30

participants). If your company’s insurance benefit covers immunizations, fill out the attached Flu Shot Clinic Insurance

Information form for each participating employee and fax them to your Costco representative.

If you’re interested in an on-site clinic, please indicate your date preferences:

First Choice: _______________________________________________ _________________________________________

DATE

TIME

Second Choice: ____________________________________________ _________________________________________

DATE

TIME

Third Choice: ______________________________________________ _________________________________________

DATE

TIME

Option #3 – If your insurance does not cover immunizations, and you’d like to utilize Costco’s claims processing

system, please contact Carrie Funk at (425) 427-3970 or for details.

Costco Internal Use

Warehouse #: ________________________ Warehouse Location: _____________________________________________

CITY, STATE

Marketing Representative Name: ________________________________________________________________________

Phone: _____________________________ Email: __________________________________________________________

Costco Flu Shot Program Form