Select A Date & Time

Select a Form*
Select A Date & Time
Appointment*

Patient Information:
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Health Card#:*
Number
Address*

Street Address

Street Address Line 2

City/StateState

Zip CodeCountry
Email
Phone Number*
Format: (000) 000-0000.
Age
Sex
SingleMarriedSeparatedWidowed
Child's Weight(Kg):
Emergency Contact
Emergency Contact-Name*
Contact’s Phone Number:*
Format: (000) 000-0000.
Relationship to Patient:

What is the reason for your test?*
Acknowledgement of Collection , Use and Disclosure of Personal Health Information.
The personal health information on this form is being collected for the purpose of providing care to you and creating an immunization record for you, and because it is necessary for the administration of Ontario's COVID-19 vaccination program. This information will be used and disclosed for these purposes, as well as other purposes authorized and required by law. For example.
- It will be disclosed to the chief Medical Offical Of Health and Ontario public units where the disclosure for a purpose of the Health Protection and Promotion Act. And
- It may be disclosed, as part of your provincial electronic health record, to health care providers who are providing care to you.
The Information will be stored in a health record system under the custody and control of the ministry of health.

Where a clinic site is administered by a hospital, the hospital will collect, use and disclose your information as an agent of the ministry of health.
I acknowledge that i have read and understand the above statement.
You may be contacted by a hospital, local public health unit, or the ministry of health for purposes related to the COVID-19 vaccine (For example, to remind you of follow-up appointments and to provide you with proof of vaccination). If you consent to receiving the follow-up communications by email or text/SMS, please indicate this using the boxes below.
By EmailBy Text/SMS
Consent to Being Contacted About Research Studies

Many research studies will be conducted by researchers about participation in COVID-19 vaccine-related research studies. If you consent to be contacted, your personal health information will be used to determine which study may be relevant to you, and your name and contact information will be disclosed to researchers. Consenting to contact about the research studies does not mean you have consented to participate in the research itself. Participating in the research is voluntary. You may refuse to consent to be contacted about the research studies without impacting your eligibility to receive the COVID-29 vaccine.

If you consent to be contacted about research studies and then change your mind, you may withdraw your consent at any time by contacting the ministry at vaccine@ontario.ca
By EmailBy Text/SMSBy PhoneBy Mail
Do Not
Signature
Print Name
Date of Signature

MonthDayYear
Date
If signing for someone other than yourself, indicate your relationship with that other person
blanks
Confirm
Patient/Agent Signature
Patient/Agent Name (& Relationship)
Patient/Agent Signed Date

MonthDayYear
Date
HEALTH CARE PROVIDER’S DECLARATION: I confirm the above named patient is capable of providing consent for seasonal influenza vaccine and that the seasonal influenza vaccine should be given to the patient. I am administering seasonal influenza vaccine no more that 21 days after the consent was signed by the Guardian or Committee, Representative, or Temporary Substitute Decision Maker of the patient.
Health Care Provider’s Signature
Health Care Provider’s License #
Date Signed by Health Care Provider

MonthDayYear
Date
Should be Empty:

Rows	Yes	No
Have you been sick or feel unwell in the past few days?
In the last 3 months, have you previously been admitted to the hospital due to a COVID-19 infection and treated with convalescent plasma or monoclonal antibodies (received treatment intravenously [By IV])?
If this is not your first dose, have you experienced any side effects from a previous dose?
Do you have a history of: 1. heparin-induced thrombocytopenia (HIT) or 2.thrombosis associated with lupus anticoagulant (thrombotic antiphospholipid syndrome) or 3. Capillary leak syndrome or 4. Cerebral venous sinus thrombosis (CVST) with thrombocytopenia or 5. venous or arterial thrombosis with thrombocytopenia a viral vector vaccine (e,g., AstraZeneca, COVISHIELD vaccines)
Have you had the diagnosis of myocarditis following the first dose of mRNA COVID-19 vaccine (e.g., Pfizer, Moderna)
Have you a known or suspected allergy or a severe anaphylactic allergic reaction (e.g. difficulties breathing, itchy/swelling of the mouth or throat, hives) to: 1. Polyethylene glycol (PEG)(PEG can be found in some products such as cosmetics, skins care products, cough syrups, and bowel preparation products for colonoscopy); or 2.Polysorbate 80 (Pllysrobate 80 may be found in medial preparations (such as vitamin oils, tables, and anticancer agents), and cosmetics); or 3. Tromethamine (Tromethamine or Tris)(Tromethamine may be found in contrast media and medications taken orally or by injection) or 4. any component of any of the COVID-19 vaccines?
Have you had severe or anaphylactic reactions to another vaccine or injection therapy in the past? (e.g., difficulties breathing, itchy/swelling of mouth or throat, hives)
Do you have symptoms of COVID-19 or have a fever today?
If this isn't your first dose, have you experienced side effects from a previous dose(s)?
In the past 14 days, did you return from travel outside of Canada or have you been in close contact with someone confirmed as having COVID 19?
Do you have an auto imune condition?
Have you been diagnosed to have COVID-19 in the past 3 months?
Have you ever had an allergic reaction such as hives or difficulty breathing, to any vaccines or shots?
Have you received any vaccine in the past 2-weeks other than for COVID-19?
Have you ever been hospitalized because of covid 19 infection? If yes were you treated with convalescent plasma or mono clonal antibodies?
Do you have a bleeding disorder or are taking blood thinners? (example warfarin, aspirin)
Are you pregnant or planning to be pregnant?
Are you currently nursing or breastfeeding a child?
Do you have a weakened immune system or are you taking any medications that can weaj=ken your immune system? (e.g., high dose steroids, anticancer medications, transplant medications?) If yes, are you receiving stem cell therapy, CAR-T therapy, chemotherapy, immune checkpoint inhibitors, medicinal antibodies or other targeted agents?
Do you have an autoimmune condition (e.g., rheumatoid arthritis, multiple sclerosis. Crohn's disease, lupus)?
Do you have any medical conditions that require visits to a primary care provider (e.g., doctor)?
Do you have a bleeding disorder or are you taking medications that can affect blood clotting (e.g., blood thinner including Aspirin, warfarin, Eliquris, Lixiana, Pradaxa, Xarelto)
Have you ever fainted after vaccination or medical procedure?
Do you have AIDS/HIV, cancer, leukemia or any condition that weakens the immune system?
Have you ever received any other vaccines in the past 14 days?
Are you taking any medication that affects your immune system, such as chemotherapy drugs, cortisone, prednisone, or other steroids, or undergoing radiation treatments?

Select A Date & Time

Patient Information:

Emergency Contact

COVID-19 Vaccine Administration

Acknowledgement of Collection , Use and Disclosure of Personal Health Information.