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Registration request for La saison de la grippe et autres virus respiratoires


Thank you for your interest in this event/program. Please complete and submit the form below.


Timeslot:
Thursday 5th Nov 2020, 4:00pm - 5:00pm
Location:
Virtual Mtg
Availability:
15 spaces remaining



Name:
Date of Birth:
Parent/Guardian:
OHIP #:
Email:
Confirm email:
 
Phone Number:
 
Address Line 1:
Address Line 2:
Town/City:
Province:
Postal Code:
Physician:
Message:
 

1. All your information is treated confidentially.

2. If you are registering on behalf of someone else (e.g. dependent, child), please enter the date of birth and health card of that person.