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* 1. Patient Name 

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* 2. Address

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* 3. Email Address

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* 4. Contact phone Number

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

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* 6. Would you like to get a COVID 19 VACCINE ***WHEN AVAILABLE***

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* 7. Are you looking for a family physician?

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

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* 10. Signature (By typing your name, you authorize staff of Bison Family Medical Center and Leila Pharmacy to utilize your medical information to facilitate the vaccination clinic. If you checked of yes to the pneumonia vaccine, your info will be shared with Bison Family Medical Clinic and Leila Pharmacy)
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

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