Vaccines - Pharma Land Pharmacy

Vaccine Request Form

Please complete the fields below. A staff member will contact you to confirm availability and finalize your appointment time.

Personal Information

First Name *

Last Name *

Phone Number *

Date of Birth *

Health Card Number (Optional)

Email Address *

Vaccine Details

Type of Vaccine *

COVID-19

Flu Shot

Other

Specify What Other Vaccine You Need

Preferred Appointment Time

Preferred Time * (a staff member will call to confirm availability)

Morning

Afternoon

Flexible

Additional Instructions (Optional)

I agree with the terms of transferring my personal data electronically, and I have read the consent to use electronic communications. *

We typically confirm appointments within one business day.

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