Covid-19 Vaccination

Please fill out the following form and select the pharmacy location that you have a confirmed appointment scheduled at. Do not fill out the form if you do not have an appointment.

Pharmacy Location

Sections A, B, C and D completed by

Patient

Parent/Guardian

Legal decision maker

Other (on behalf of client)Other (on behalf of client)

A. Client Information

Last Name *

First Name *

Address of residence *

City/Town

Postal Code *

Phone Number *

Sex *

Male

Female

Date of Birth *

Ontario Health Card # *

Emergency Contact Name and Phone

Primary Care Physician/Nurse Practitioner Name

Physician/NP Tel