MENINGITIS VACCINE CLINICS
Student Name
*
Student Birthdate
*
-
Month
-
Day
Year
Date Picker Icon
Gender
Male
Female
BC Care Card Number
Name of Parent/Guardian/Representative,
*
Relationship to child
Day Phone Number
*
Evening Phone Number
Cell Phone
School
*
Physician's Name
Physician's Address
Clinic Date and Option
May 6, 2016 - 1st Dose of (4CMenB) - BEXSERO®
May 18, 2016 - MCV4 (A, C, W-135 & Y) - MENVEO-tm
June 10, 2016 - 2nd Dose of (4CMenB) - BEXSERO®
All student must have consent form complete.
Download consent form here.
Payment for one dose of vaccine.
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1 dose of vaccine
$
123.90
CAD
2 doses of vaccine
$
247.80
CAD
3 doses of vaccine
$
371.70
CAD
Total
$
0.00
CAD
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