East End Community Health Centre Flu Shot Notification

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* 1. Please provide your email address:

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* 2. Please provide the best phone number to reach you at:

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* 3. Please enter the name(s) of those in your household who will be receiving the flu shot (minimum age 6 months):

Name

Name

Name

Name

Name

Name

Name

Name

Name

Name

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* 4. How many members of your household who will be receiving the flu shot are between the ages of 6 months and 64 years? Please enter the information as a number, i.e. 1, 2, 3.

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* 5. How many members of your household who will be receiving the flu shot are 65 years of age or older? Please enter the information as a number, i.e. 1, 2, 3.

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* 6. Have you (or members of your household) ever previously received a flu shot, or any other service, from East End Community Health Centre?

Yes

No