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FLU VACCINATION REGISTRATION FORM
1.
Member Details:
Name:
Age:
Phone Number:
2.
Which scheme do you belong to?
3.
Where do you reside? (This will help us recommend the nearest and most convenient facility)
4.
What is your preferred facility to receive the vaccination?
One Stop Pharmacy
Aga Khan University Hospital
Equity Afya
AAR Healthcare
Thank you for your response!
