Name

Address:

Email

Phone

Date of Birth (YYYY/MMM/DD)

OHIP# (10 Digits+ 2 Letter VC)

Are you an existing patient of ProHealth PharmaChoice?

Yes
No
Not Sure

Type of Pharmacist Appointment

COVID-19 Vaccination
Flu Shot High Dose Age 65+
Flu Shot Regular
Vaccine Injection Service (Shingrix, Prevnar, etc...)
Pharmacist Consult at Pharmacy
Pharmacist Consult by Phone
MedsCheck Medication Review

Preferred Date, Time, and Reasons for the Pharmacist Appointment