Middlesex Centre Family Medicine Clinic COVID-19 Vaccination Pre-Registration Form
Pre-register for upcoming COVID-19 vaccination clinics. We will call you back to schedule an appointment when they become available.

This Google Form is not PHIPA-compliant, and as such, we will not be collecting any details other than name, birthday and contact info. No personal health information should be shared in this form. It is simply for the purpose of adding to a waitlist.
Full Name: *
Date of Birth: *
Phone Number: *
I am looking for:
Clear selection
If you are looking for your second dose, please indicate the date and type of vaccine you received for your first dose.
I consent to this information being collected acknowledging the fact that Google Forms may not meet all Health Care Privacy requirements.
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