Fall Vaccination Appointment Booking Form

Confirmation Message will pop-up here!

Client's First name

Client's Last name

Date Of Birth (mm/dd/yyyy)

Gender

Ontario Health Card #

Enter only numbers with no letters, dashes or spaces, eg.0000000000

Alternate ID type (if Health Card is not available)

Vaccines Requested:

Note: Co-administration of Influenza (flu) and Covid-19 vaccines is recommended this respiratory season. Please also note, for the Covid-19 vaccine, the recommended interval from previous dose or known infection is 6 months (as a longer interval results in a more robust and durable immune response and higher vaccine effectiveness), however, guidance from MOH and NACI notes that a shorter interval (3 to <6 months) can be considered to support the fall booster program.

I would like influenza vaccine and Pfizer COVID-19 vaccine

I would like influenza vaccine and Moderna COVID-19 vaccine

I would like influenza vaccine only

I would like Pfizer COVID-19 vaccine only

I would like Moderna COVID-19 vaccine only

Would you like a Reminder?

Yes

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

e.g. abc@xyz.com

Cell Phone

e.g. 000-000-0000

Book appointment

Date

No dates are available

Time

No time slots are available

I confirm that I have read and understand the Influenza Vaccine factsheet and am aware of the Covid-19 Vaccine information resources

I have read, understand and agree to the Grand Erie Public Health’s Privacy Statement regarding the collection of information.