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:

Shingles
Twinrix
Hepatitis A
Hepatitis B
Gardasil (HPV)
Pneumonia
Meningitis
Typhoid

Please note: A prescription may be required for vaccines. You can download the consent form, print it and bring it with your information filled at your appointment. If you do not have a printer, we have copies at the pharmacy. Download the 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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