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Pharmacie Labib Fraih and Manal Karzon SENC
Travel Consultation and Vaccination

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Montreal Yellow Fever Vaccination Appointment

DEMANDE DE VACCINATION FIÈVRE JAUNE

First name*

Name*

E-mail*

Phone*

Address*

Date of birth*

Day

Month

Year

Are you pregnant or breastfeeding?*

Yes

No

Have you ever been vaccinated against yellow fever?*

Yes

No

Have you ever experienced significant adverse reactions following a vaccination?*

Yes

No

Do you have a thymus disease (thymoma, thymectomy, myasthenia gravis)?*

Yes

No

Do you have an immune system disorder (e.g. lymphoma, leukemia, HIV/AIDS, taking certain medications such as chemotherapy or a biological agent)?*

Yes

No

Do you have any known health problems?

Departure date for the trip

Countries and cities visited

Initials*

I declare that I have read the information located in the Remote Pharmaceutical Services section and I consent to use the technology to receive my pharmaceutical services remotely.

Please fill out and submit this form. We will contact you as soon as possible to schedule an appointment.
Your private drug insurance may cover part of the cost of prescribed vaccines. If you would like us to add your drug insurance to your file, please send us a photo of your drug insurance card to pharmaciepetitepatrie@gmail.com

This page is for booking appointments for yellow fever vaccination only. For travel vaccination consultations, please fill out the following form:
www.vaccinationvoyage.ca/consultation-voyage

937 St-Zotique East, Montreal H2S 1M9
514 370-2626
pharmaciepetitepatrie@gmail.com

Labib Fraih Pharmacy and
Manal Karzon SENC

Pharmacists are solely responsible for the practice of pharmacy.

© 2025 Fraih and Karzon Pharmacy

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