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Clinic Registration Form

Use this form to register a clinic or practice group. If expenses will all be claimed by the clinic, you can also add your direct deposit information.

Registration Form

The following form should be completed for each medical clinic and/​or physician who anticipates participating in, and claiming expenses or remuneration under the COVID-19 vaccination initiative.

A. Clinic Information

B. Point Person Information

Please identify a point person who can serve as a main contact for Doctors Manitoba, the Manitoba College of Family Physicians and other partners involved in this initiative.

C. Participating Physicians

Please list all physicians in this clinic who will participate in the vaccine initiative, either with vaccine outreach or with vaccine clinics. (to add additional physicians, please click ​“Add Row”)

Physician Name Phone Number Email Address

D. Payment Preference

Under the initiative, clinics and/​or individual physicians can claim expenses to support vaccine outreach and vaccine clinics.

(5 digits)
(3 digits)
Please enter your account number

Thank you, we will email you a link to add banking information for each individual physician.

Please note: the name and contact information of participating clinics and physicians may be shared with initiative partners, including the Manitoba College of Family Physicians, Manitoba Health, and/​or University of Manitoba. Banking information will not be shared and will only be retained to facilitate payment.

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