ISPA Clinic Registration Form

Client and Vaccine Info
Confirmation

Appointment

Book add on

Date

No dates are available

Time

No time slots are available

Client Details

First name

Last name

Date Of Birth (yyyy/mm/dd)

Gender

Ontario Health Card #

e.g..0000000000

Postal Code

e.g. M1M 1M1

Do you have a family physician?

Yes

If yes, what is the physician's full name?

Would you like to receive confirmation and reminder about your vaccine appointment?

Yes

By selecting YES you are agreeing to BCHU to use your email and/or phone number to send you confirmation and reminders about your vaccination appointment as well as confirmation of appointment cancellation or rescheduling. The contact information provided will not be used for any other purpose.

e.g. abc@xyz.com

Cell Phone

e.g. 000-000-0000

Comments

Vaccines Required

Vaccine

Client to Pay?

Yes

I have read, understand and agree to the Brant County Health Unit’s Privacy Statement regarding the collection of information.

Confirmation message

Confirmation Message will pop-up here!