2022 Flu Shot Dose Sign Up Sheet

PLEASE REVIEW ALL INFORMATION CLOSELY.

We will call you to book you for a FLU vaccine appointment. At this time we are requesting that only our HIGH RISK patients add their names to the call-back list.

Completion of this form authorizes us to use your email address to contact you. It also provides consent for us to collect your personal information which is being stored on a password protected Google-platform website.
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Email *
Please confirm that you are an existing active patient at Brameast Family Health Organization. Please do not add your name to this list if you are not a patient in this practice. *
Required
Last Name (as listed on your health card): *
First Name (as listed on your health card) *
Best Phone number to reach you (day #): *
Can we leave a detailed message at this phone #? *
Please confirm your age (years) *
Please select condition that most accurately applies to you: *
Select your family physician from the following: *
Thank you for adding your name to the waiting list. Please acknowledge each of the following:
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