Name
Date of Birth
Information
Smoker?
Allergies
Please indicate if you have any of the following conditions
Do you need Influenza or Pneumococcal vaccinations?
Do you need assistance with walking aid selection or Compression stockings
Note: There are fees associated with the services not covered by Alberta Health described on this form (ex. vaccines, pharmacogenomics testing and travel education). Some of these may be covered through 3rd party insurance. Please contact the store for more information. Travel Note: Vaccines are generally well tolerated. Some patients may experience some soreness, redness and swelling at the injection site. As with any vaccine, other side effects including an allergic reaction or anaphylactic response could occur.
Please call 780-476-4747 to book your COVID-19 vaccination and one of our team members will be happy to assist you. The online booking is temporarily down.