Protect your employees from the flu: order form

If you are not a Mensura client, please complete the form below untill 29 September to order your flu vaccines. We will contact you to fix a suitable vaccination date and time.

If you are already a customer, you can order your vaccines via the client zone.

The fields with an * must be completed.

About your organisation

Name of your organisation *

Department *

Street name and house number (+ box) *

Postcode *

City *

Contact *

Position *

E-mail *

Telephone number *

Enterprise number *

VAT number

Which External Service are you affiliated with? *

Invoice address (if that differs from the address above)

Street name and house number (+ box)

Postcode

City

Number of vaccines

Number of vaccines: *

While stocks last. If stocks have been depleted, Mensura will inform you via phone.

At which location do you want to vaccinate your employees?

1. I choose to vaccinate at our establishment (minimum 20 vaccines).

Street name and house number (+ box)

Postcode

City

2. I choose to vaccinate at a Mensura consultation centre (minimum 1 vaccine).

Choose your preferred centre

Confirmation

I confirm this order and agree to pay the invoice. Number of flu vaccines ordered = number of vaccines invoiced. *

I agree.

Name of your organisation *

Date *

Check the box confirming you are not a robot. That way we know your registration is not spam.