(613) 746-4555
Fax: (613) 746-5444
info@pharmalandpharmacy.ca
Mon. - Fri 9:00 AM - 5:30 PM Sat. 9:00 AM - 2:00 PM

VACCINE REQUEST FORM

First Name: *

Last Name: *

Phone Number: *

Date of Birth *

Health Card Number (Optional)

Email Address: *

Type of Vaccine *

COVID-19

FLU SHOT

OTHER

Specify What Other Vaccine you need

Preferred time (A staff member will call to confirm the availability): *

Morning Appointment

Afternoon Appointment

Flexible schedule

Additional Instructions (Optional):

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