Willows Squash and Fitness Centre

Flu Vaccination Program

Client 1

Client Details

Attendee First Name

Attendee Last Name

Email Address

Confirm Email Address

Mobile/Cell

Flu Vaccination Program Dates

From 15-May-2019 to 31-Jul-2019

DISCLAIMER:
Once we receive payment, you will be emailed a letter with a unique code and instructions to book an appointment online with the TerryWhite Chemmart of your choice). Visit your chosen TerryWhite Chemmart to be administered your Flu Vac.

Agreement

Signed

Date

/ /

Payment Method

Once we receive payment, you will be emailed a letter with a unique code and instructions to book an appointment online with the TerryWhite Chemmart of your choice). Visit your chosen TerryWhite Chemmart to be administered your Flu Vac.

Cost

$19.50

Cost Per Person

$19.50

Total Cost

Group Discount

Promo Code

Promo Code Discount

Grand Total

Credit Card (Ezidebit)