COVID & FLU Vaccine clinic sign up
COVID and FLU Vaccine Clinic 

THIS Saturday NOV 19th, 2022
9 am to 11:30 am. 

Hosted by Omni Medical
at "Charities House" 25 Point Finger Road, Paget

Please drive to the BACK of the Charities House to where the pop up vaccine tent is located.

LIMITED NUMBER OF VACCINES AVAILABLE

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Email *
Last Name *
First Name *
Date of Birth *
DD MMM YYYY (e.g. 21 May 2022 - day month year)
Email address *
Health Insurance Coverage
Co-pay may be applicable depending on your health insurance coverage.  
Without insurance coverage, a $30 charge will be levied for each vaccine shot (Covid or Flu)
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Health insurance number
please include Group and Certificate number or enter "N/A" if not applicable
Phone number  *
Please provide AT LEAST ONE(1)  phone number so we can reach you if needed.
Covid vaccine shot # and/or FLU vaccine *
Required
Appointment time slot preference *
Please Choose your preferred time slot. If the slot is no long available, we will contact you.
Any additional information you want to provide *
A copy of your responses will be emailed to the address you provided.
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