Flu Clinic Appointment Booking Form

Confirmation Message will pop-up here!

Client's First name

Client's Last name

Date Of Birth (mm/dd/yyyy)

Gender

Ontario Health Card #

Enter only numbers with no letters, dashes or spaces, eg.0000000000

Alternate ID type (if Health Card is not available)

Would you like a Reminder?

Yes

By selecting YES you are agreeing to BCHU to use your email and/or phone number to send a confirmation of registration and reminders about your vaccination appointment. The contact information provided will not be used for any other purpose.

e.g. abc@xyz.com

Cell Phone

e.g. 000-000-0000

Book appointment

Date

No dates are available

Time

No time slots are available

I confirm that I have read and understand the Influenza Vaccine factsheet.

Please note that if you have any of the following conditions, you will be unable to receive the flu shot with the Brant County Health Unit:

Current serious acute illnesses (delay vaccination until symptoms resolve)
Pregnant and breastfeeding individuals
History of allergic reaction or hypersensitivity to a previous dose of inactivated influenza vaccine or to any vaccine component
History of Guillian- Barrè Syndrome (GBS) within 6 weeks of receipt of prior dose of influenza vaccine
History of Oculorespiratory Syndrome (ORS) within 24 hours of receipt of prior dose of influenza vaccine
Diagnosis as immunocompromised
Diagnosis of a bleeding disorder

I acknowledge that I do not have any of the above conditions that would exclude me from receiving my flu shot with the Brant County Health Unit.*These conditions may not exclude you from receiving the flu shot with your health care provider - we encourage you to follow up with them to discuss the risks and benefits of influenza vaccination and to receive the vaccine if appropriate.*

I have read, understand and agree to the Brant County Health Unit’s Privacy Statement regarding the collection of information.