*1.Patient Name (Required.)

First Name

Last Name

2.Address

Address line 1

Address line 2

City

Province

Postal Code

*3.Email Address(Required.)

*4.Contact phone Number(Required.)

*5.Would you like to get a Pneumonia Shot?(Required.)

Yes

No

*6.Would you like to get a COVID 19 VACCINE?(Required.)

Yes

No

*7.Are you looking for a family physician?(Required.)

Yes

No

*8.Would you be interested in receiving information on physician supported weight management programs?(Required.)

Yes

No

*9.Which of our 7 clinics would you prefer to attend for your flu shot?(Required.)

Bison Family Medical Clinic, I-80 Bison Drive, Winnipeg, MB, R3T 4Z7Bison Clinic on Pembina, 1686 Pembina Hwy, Winnipeg, MB, R3T 2G2St. Anne's Medical Clinic-215 St Anne's Rd, Winnipeg, MB R2M 2Z9Regent Superstore Clinic-1578 Regent Ave W, Winnipeg, MB R2C 3B4Gateway Superstore Clinic-1035 Gateway Rd, Winnipeg, MB R2K 4C1Norwood Medical Centre-43 Marion St A, Winnipeg, MB R2H 0S8Harbourview Medical Centre-1320 Concordia Ave E #10, Winnipeg, MB R3W 0G6

*10.Signature (By typing your name, you authorize staff of Bison Family Medical Clinics Inc to utilize your medical information to facilitate the vaccination clinic). 
Upon receiving your consent, staff will contact you to schedule your appointment. On the day of the flu shot, please ensure you
-wear a mask for the appointment
-Are feeling well (No fever, coughing or other symptoms)
-Bring your Manitoba health card(Required.)