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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.

*1.Please enter your name and contact information
(Required.)

Name

Clinic/Practice Name

City/Town

Email Address

Best Contact Phone Number

2.What is your general availability?

Check all that apply

Weekdays (with notice)

Weekday evenings

Weekends

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

4.Comments

Current Progress,

0 of 4 answered

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