St. Andrew Pharmacy
Thank you for your interest in receiving Flu vaccine. Please schedule a time to receive it below.
Full Name
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date of Birth
Health Card #
*
Please fill in your Health Card #
E-mail
*
example@example.com
Address
*
Street Address
City
Province
Postal Code
Phone Number
*
Flu Vaccine Appointment
*
Submit
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