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Healing Source Pharmacy Flu Shot Request Form
Please fill in the information in this form. We will contact you within 3 business days to book your flu shot appointment at our pharmacy.
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* Indicates required question
Name (First and Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Home Postal Code (e.g. M1P M8M)
*
Your answer
Email (e.g.
johndoe@gmail.com
)
*
Please ensure your email is written correctly.
Your answer
Telephone (where we can reach you )
*
Please ensure your telephone number is written correctly.
Your answer
Please download and print the flu shot vaccination consent form. Please complete the form before your appointment.
Download Form.
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