Expression of Interest in the COVID-19 Vaccine Distribution Program

This form is for primary care providers to indicate an interest in the Middlesex-London COVID-19 Vaccine Distribution Program.

Note: You are not required to join the program if you fill out this form. This is simply so we can send you more program information.

*Facility Name

*Street Address

*City

*Postal Code
Format A0A 0A0

*COVID-19 Vaccine Lead (who MLHU will work with to facilitate the program):

*Lead Phone Number

*Lead Email Address

Confirm email address

*Do you currently administer vaccine (i.e. influenza) and is your fridge inspected on an annual basis by MLHU?

Yes

Do you have any questions or concerns that MLHU should be aware of?