Fill out the form below to book your FLU SHOT appointment:

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Name:*

First

Last

Phone:*

Area Code

Phone Number

Date of Birth:*

Day

Month

Year

Passport Number (If applicable):

Health Card Number (Ontario ONLY) (If applicable):

Gender:*

E-mail:*

Home Address:*

Street AddressCityState / Province / RegionPostal / Zip Code

Preferred time (A member of our medical staff will call to confirm the availability):*

9 AM - 1 PM

1 PM - 5 PM

Flexible schedule

Additional Instructions (Optional):

Word Verification: