Bison Family Medical Flu Shot Clinic Question Title * 1. Patient Name First Name Last Name Question Title * 2. Address Address line 1 Address line 2 City Province Postal Code Question Title * 3. Email Address Question Title * 4. Contact phone Number Question Title * 5. Would you like to get a Pneumonia Shot? Yes No Question Title * 6. Would you like to get a COVID 19 VACCINE? Yes No Question Title * 7. Are you looking for a family physician? Yes No Question Title * 8. Would you be interested in receiving information on physician supported weight management programs? Yes No Question Title * 9. Which of our 7 clinics would you prefer to attend for your flu shot? Bison Family Medical Clinic, I-80 Bison Drive, Winnipeg, MB, R3T 4Z7 Bison Clinic on Pembina, 1686 Pembina Hwy, Winnipeg, MB, R3T 2G2 St. Anne's Medical Clinic-215 St Anne's Rd, Winnipeg, MB R2M 2Z9 Regent Superstore Clinic-1578 Regent Ave W, Winnipeg, MB R2C 3B4 Gateway Superstore Clinic-1035 Gateway Rd, Winnipeg, MB R2K 4C1 Norwood Medical Centre-43 Marion St A, Winnipeg, MB R2H 0S8 Harbourview Medical Centre-1320 Concordia Ave E #10, Winnipeg, MB R3W 0G6 Question Title * 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 Done