COVID-19 Vaccine Program Registration Form For Pharmacies

Health and Seniors Care

Communicable Disease Control

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COVID-19 Vaccine Program Registration Form For Pharmacies

Pharmacies that would like to participate in Manitoba’s COVID-19 Immunization Program must register with Manitoba Health and Seniors Care and identify that they can meet all the requirements identified on COVID-19 Vaccine Program Requirements document.

Please submit only ONE registration form per pharmacy.

Pharmacy Information

Client ID#:

Note: Client ID # (also referred to as Holding Point Code) is the number currently used to order publicly funded vaccines from the Provincial Distribution Warehouse.

Health Region:

Primary Contact on site at the Pharmacy:

Email Address:

Phone Number:

Fax Number:

Number of immunization providers:

Pharmacy Delivery Address

Delivery Street Address (include unit number and street name):

Delivery City:

Province:

Delivery Postal Code:

Type of Pharmacy:

Pharmacy Name:

Corporation Legal Name:

Contact Name:

Email Address:

Phone Number:

Is corporation address different than the delivery address? Yes No

Corporation Address

Corporation Street Address (include unit number and street name)

Corporation City

Province:

Corporation Postal Code

Authorization

Submitting this form indicates that you, on behalf of the pharmacy, have reviewed and agree to follow the program requirements to participate in Manitoba’s COVID-19 Immunization Program.

Full Name

Date

I have reviewed and will follow the COVID-19 Vaccine Program Requirements to participate in Manitoba's COVID-19 Immunization Program I agree I disagree