Vaccination Assistance Offer

Thank you for your interest in helping to serve as an immunizer for large employers or community-based pop up clinics.

Please complete the form below. The names and contact information for interested physicians will be shared with the Manitoba government or organizations planning pop-up vaccination clinics.

Question Title

* 1. Please enter your name and contact information

Name

Clinic/Practice Name

City/Town

Email Address

Best Contact Phone Number

Question Title

* 2. What is your general availability?

Check all that apply

Weekdays (with notice)

Weekday evenings

Weekends

Question Title

* 3. When are you available?

Check all that apply

Week of July 5

Week of July 12

Week of July 19

Week of July 26

Week of Aug 2

Week of Aug 9

Week of Aug 16

Week of Aug 23

Week of Aug 30

Vaccination Assistance Offer

Question Title

* 1. Please enter your name and contact information

Question Title

* 2. What is your general availability?Check all that apply

Question Title

* 3. When are you available?Check all that apply

Question Title

* 4. Comments

* 2. What is your general availability?

Check all that apply

* 3. When are you available?

Check all that apply