Vaccination Request Form

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This form is to be completed for adults who would like to receive one of the following vaccines:

RSV
Pneumonia
Shingles
Twinrix
Hepatitis A
Hepatitis BGardasil (HPV)
Pneumonia
Meningitis
Typhoid

Please note: A prescription may be required for vaccines. Once you are at the pharmacy for your appointment, we will ask you to complete a vaccination consent form. View consent form.

Cost per vaccine

Fee for administering vaccines is $20 each (does not include the cost of the vaccines), which you may be able to submit to your private insurance.

Please note some vaccines may require multiple doses. (To complete the series, vaccines for: shingles requires 2 doses, hepatitis B 3 doses, hepatitis A 2 doses, hep A&B combination 3 doses, HPV 3 doses).

Please select your vaccine:
*

Name (First and Last) *

Date of Birth* *

YYYY

Home Postal Code (e.g. M1P M8M)* *

Email (e.g. janedoe@email.com)* *

Telephone (where we can reach you)* *

Submit

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