Flu Shot Form | Health Information Form

The best way to prevent the flu is by getting the influenza vaccine, also known as the flu vaccine or “flu shot”. The influenza vaccine is safe and effective and the best way to prevent getting the flu and transmitting it to others.

Our pharmacists are able to administer the flu vaccine to persons 5 years of age and older.

Step 1 of 5

Health Information for your Flu Shot
Please note: to increase accuracy of this information, please complete no sooner than 24 hours prior to your vaccine appointment.
Covid-19 Screening Questions
1. Do you have any of the following new or worsening symptoms: fever/chills, cough, difficulty breathing/shortness of breath, sore throat/difficulty swallowing, runny nose, loss of taste, etc.?*
- Yes
- No
2. In the last 14 days, have you had close physical contact with a person who has been confirmed to have COVID-19, who is experiencing the symptoms listed above or with someone who returned from travel outside of Canada?*
- Yes
- No
3. In the last 14 days, have you travelled outside of Canada?*
- Yes
- No
If you have answered yes to any of the above questions, please do not proceed with the questionnaire and contact your local Public Health Authority (8-1-1)

Name*
First Last
Health card number*
Please note: Pharmacists are only able to administer influenza vaccines to persons greater than 5 years old. If the child is less than 5 years old, please book an appointment with your health care provider or Public Health.
Date of Birth*
Civic Address*
Street Address Address Line 2 City Province Postal Code
Phone Number*
Date of Flu Vaccination Appointment*
Month
Day
Year

Sex*
- Female
- Male
- Other
Age*
Emergency Contact Name*
First Last
Emergency Contact Phone*

Our pharmacists are able to administer the flu vaccine to persons 5 years of age and older.

Step 1 of 5

Health Information for your Flu Shot