Flu Shot Information

Name

First Name

Last Name

Date of Birth:

YYYY

Healthcard (OHIP) Number:

Please put in your healthcard number and the TWO letter version code at the end.

Your Postal Code:

Date of flu vaccination:

If you do not know the exact date, just enter the month and year and put the day as '01'

YYYY

If you have received a flu shot please let us know the details so we can update your records.

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