Please complete this form if each physician will be paid individually for any vaccine initiative expenses claims. This should be completed after the clinic has been registered for the initiative

Banking Information

(5 digits)
(3 digits)
Enter your account number

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/‚Äčor University of Manitoba. Banking information will not be shared and will only be retained to facilitate payment.