CREDIT VALLEY HEALTH CENTER
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Flu Vaccine Consent Form
Request an Appointment with one of our Doctors
*
Indicates required field
Name
*
First
Last
Date of Birth (dd/mm/yyyy)
*
Health Card
*
Version Code
*
Phone Number
*
Email
*
Doctor
*
Dr. Maha Hadi
Dr. Saadia Khan
Dr. Shaheen Manzoor
Dr. Kiran Humayun
Dr. Mohammed Imana
Dr. Sohail Cheema (Paediatrician)
Dr. Mohammed Azharuddin (Endocrinologist)
Dr. Mustafa Al-Maini (Allergy & Immunology)
Dr. Balbhadar Sood (Psychiatrist)
Dr. Mohammad Amin Hussain (Hematologist)
Dr. Melissa Chan (Naturopathic Doctor - Non OHIP)
Sabra Desai (Psychotherapist - Non OHIP)
Reason for Visit
*
Sick/Unwell
Follow up re: results
Physical
Prenatal
Referral/Consultation
Well baby check
Immunization
Flu Vaccine
Other
if you selected other, please describe the reason
*
Is this an urgent matter?
*
Urgent
Non-Urgent
Staff will triage each request based on all information given. If you feel that it is an emergency, please go to the nearest Hospital Emergency Dept.
Symptoms (Check all that apply)
*
N/A
Fever
Cough
Respiratory
Pain
Rash/Skin issue
Mental Health
Other
Please further describe your symptoms
*
How long have you been having these symptoms
*
N/A
1 day or less
2-3 days
3-7 days
7+ days
Have you taken any medications to manage your symptoms?
*
N/A
Yes
No
If yes, please list the medications you have taken
*
Please note: You will receive a call/email from staff to book an in-person appointment OR a phone call appointment with the doctor
Submit
Home
RX RENEWAL
Request Appointment
Book With Hazel
REGISTER
FHO After Hours
Speak to a Receptionist
Flu Vaccine Consent Form