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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Confirm your vaccine brand
 *
Required
Are you booking for: *
When did you receive your last dose of COVID-19 vaccine? *
If you are not requesting for first dose, please enter today's date.
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/
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Name (First and Last) *
Date of Birth *
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YYYY
Home Postal Code (e.g. M1P M8M) *
Email (e.g. janedoe@email.com) *
Telephone (where we can reach you) *
Please download and print the COVID-19 vaccination consent form. Please complete the form before your appointment. Download Form.
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