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COVID-19 Vaccination Request Form
This form is to be completed for those who would like to receive their adult COVID-19 vaccine at Healing Source Pharmacy.
Vaccinating children 12 years and older.
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* Indicates required question
Confirm your vaccine brand
*
Adult - Pfizer XBB
Required
Are you booking for:
*
Choose
1st dose COVID-19 vaccine.
2nd dose COVID-19 vaccine.
3rd dose COVID-19 vaccine.
4th dose COVID-19 vaccine.
5th dose COVID-19 vaccine.
6th dose COVID-19 vaccine.
7th dose COVID-19 vaccine.
8th dose COVID-19 vaccine.
When did you receive your last dose of COVID-19 vaccine?
*
If you are not requesting for first dose, please enter today's date.
MM
/
DD
/
YYYY
Name (First and Last)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Home Postal Code (e.g. M1P M8M)
*
Your answer
Email (e.g.
janedoe@email.com
)
*
Your answer
Telephone (where we can reach you)
*
Your answer
Please download and print the COVID-19 vaccination consent form. Please complete the form before your appointment.
Download Form.
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