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

Remove Clinic

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:*

Language Preference: English French

Communication Preference: E-mail Fax

Where did you hear about Vaccines411?

Web Search

Facebook

Colleague

CPHA

Other

If Other, Please specify:

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:

Do you have a minimum age requirement?: Yes No

Specify:

Teenagers and Adults

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

Adults 50+

Influenza	Pneumococcal Conjugate	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

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Clinic Information

Infants and Children

Teenagers and Adults

Adults 50+

Travel

Seasonal

Other

Special Instructions or Notes