Middlesex Centre Family Medicine Clinic COVID-19 Vaccination Pre-Registration Form

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Middlesex Centre Family Medicine Clinic COVID-19 Vaccination Pre-Registration Form

Pre-register for July 23, 2021 COVID Vaccination Clinic.

This Google Form is not PHIPA-compliant, and as such, we will not be collecting any details other than name, birthday and contact info. No personal health information should be shared in this form.

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Full Name: *

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Date of Birth: *

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Phone Number: *

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I am looking for:

First dose

Second dose

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