Warkworth Pharmacy Flu Shot & COVID Form

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Warkworth Pharmacy Flu Shot & COVID Form

Thank you for your interest in either the annual influenza vaccine and/or the newest COVID-19 vaccine. Please fill in your information below.

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* Indicates required question

Name *

Your answer

How old are you? *

Your answer

Do you have an Ontario Health Card? *

Yes

No

Phone number (Home) *

Your answer

Phone number (Cell)

Your answer

Email Address

Your answer

Would you like the 2023-2024 Influenza Vaccine? *

Yes

No

Would you like the COVID-19 Vaccine? *

Yes

No

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