Request Appointment

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 *

Reason for Visit *

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

Credit Valley Health Center
16-2555 Erin Centre Blvd
Mississauga ON, L5M 5H1
Phone: 905-828-0270
Fax: 905-828-0277

Home
RX RENEWAL
Request Appointment
Book With Hazel
REGISTER
FHO After Hours
Speak to a Receptionist
Flu Vaccine Consent Form