CALL US
780-476-4747
E-MAIL
info@apollopharmacy.ca
LOCATION
6570 170 Ave NW

Health Review & Care Plan Appointment Form

Name

Date of Birth

Information

Allergies

Egg AllergyLatex AllergyDrug Allergy

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.