Clinic Information

If you are a physician or clinic and wish to add, edit or remove your clinic from the list of locations where vaccines are available, please fill out the form below. A representative will contact you shortly regarding your request.

This form can be accessed at any time to update your profile.

Add Clinic

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Edit My Information

All fields marked with an * are required

Clinic:*

Contact Person:*

Secondary Contact:

Address:*

City:*

Province:*

Postal Code:*

Phone Number:*

Fax Number:

Website:

E-mail Address:*

Please select all vaccines that are available at your clinic/office.

Infants and Children

DTaP	Hepatitis B	Hib	HPV
Influenza	Meningococcal Group C Conjugate	MMR	Pneumococcal Conjugate
Polio	Rotavirus	Varicella
Other If Other, Please specify:

Teenagers and Adults

Hepatitis B	HPV	Meningococcal Conjugate Quadrivalent	Tdap
Other If Other, Please specify:

Adults 50+

Influenza	Pneumococcal Polysaccharide	Shingles	Tetanus
Other If Other, Please specify:

Travel

Cholera	Tick-borne Encephalitis	Hepatitis A	Hepatitis B
Hepatitis A + B	Influenza	Japanese Encephalitis	Meningococcal Conjugate Quadrivalent
Meningococcal Polysaccharide Quadrivalent	MMR	Pneumococcal Polysaccharide	Polio
Rabies	Tetanus	Tuberculosis (BCG)	Typhoid
Varicella	Yellow Fever
Other If Other, Please specify:

Seasonal

Influenza	Pneumococcal Polysaccharide
Other If Other, Please specify:

Other

PPD (Mantoux test)	Rabies	Tetanus
Other If Other, Please specify:

Special Instructions or Notes

Last Updated: March 5, 2012

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