Interior Health - Immunizer Form
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This form is intended for health-care professionals interested in helping with immunizations at one or more of Interior Health’s COVID-19 Immunization Clinics. Expressing an interest does not automatically commit you to the program. You will be contacted by a Public Health representative in the coming weeks to discuss your availability.
Personal Demographics
First Name
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Last Name
*
Town/City
*
Please provide one or more of the following phone numbers:
*
Home Phone
Cell Phone
Other Phone
Other Phone Belongs To
*
Preferred Contact Number
*
Please select
Home
Cell
Other
E-mail
Availability and Experience
What communities are you willing to help immunize in? Please list the name of each town or city:
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I am available on the following days:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
I am available starting from
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I am available until
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To help us understand your experience and determine where you will be the most help, please select from one of the following options:
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I am currently a practising nurse/physician/pharmacist or other health-care professional with experience in immunizations.
I am a retired (non-practising) nurse/physician/pharmacist or other health-care professional with experience in immunizations.
I have no clinical health-care experience.
Regardless of the option selected above, you will be contacted by a Public Health representative who will provide or obtain additional information.
Profession
*
Please select
Midwife
Anesthesiology Assistant
Dental Hygienist
Dentist
First Responder
Non-Clinical
Non-Practicing Physician
Nursing Student
Paramedic
Pharmacist
Practicing Physician
Registered/Licensed Nurse (RN/LPN/RPN)
Unregistered Nurse
Other
Applicable License number
Comments:
Please check each statement to acknowledge you have read our site policies, and then click submit form to Interior Health
*
I have read and fully understand this notification with regards to the collection, storage, and use of my personal information
(click here to review)
I,
certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.
Please leave this field empty
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