COVID-19 Vaccine Appointment Request
PLEASE NOTE - WE MAY NOT BE ABLE TO ACCOMMODATE YOUR REQUEST AS VACCINE AVAILABILITY IS NOT GUARANTEED AND IS LIMITED AT THIS TIME. IF AVAILABLE, WE WILL SEND AN EMAIL WITH THE CONSENT FORM TO BOOK AN APPOINTMENT. PLEASE DO NOT CALL THE CLINIC.
PLEASE NOTE WE ARE AWAITING OUR NEXT SUPPLY OF VACCINE.
Do you have a valid OHIP card? *
Patient First and Last Name *
Patient Date of Birth *
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DD
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Were you born before December 31, 1961? *
Do you live and/or work in Peel Region? *
How did you hear about the vaccine at West Mississauga Medical? *
Patient Email Address *
Best Number to Reach You: *
Would you like to book an appointment to receive the Covid-19 Vaccine? *
Would you like to speak to a doctor before booking an appointment? *
Have you been seen by a doctor at West Mississauga Medical in the past? *
By signing my name below, I agree that all the information I have provided is true to the best of my knowledge. *
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