Pharmasave Northwoods Village Vaccine Consent Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Personal Health Number
4
Phone* This field is required.
Please enter a valid phone number.
5
Birthdate * This field is required.
Month
Day
Year
6
Address* This field is required.*The address for shipping of the travel medications, travel handouts and travel immunization records.
Address Line 1
Street Address Line 2
City
State / Province / Region
Postal Code
Canada
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Emergency Contact* This field is required.
Full name (Emergency contact)
Phone number (Emergency contact)
8
Which Vaccines do you require?* This field is required.Please note for this type of appointment we do not provide any recommendations or medications. If you are unsure which vaccine(s) you require or need anti-malarial/antibiotics, please book a travel consultation as we are unable to recommend on-site.
Huge
Large
Normal
Small
Ok
Ok
9
Is this an initial dose or a booster shot?* This field is required.
Initial dose
Booster shot
Other
10
Please expandWhich dose of booster shot? e.g. 1st, 2nd, 3rd or 4th
11
MMR (Measles/Mumps/Rubella) Eligibility* This field is required.(To allow for requisition of MMR dose from Public Health)
I was born before 1970 with no history of measles infection and require a booster dose
I was born before 1970 with no documentation or recollection of measles vaccination and require a booster dose
I was born after 1970 with no documentation of measles vaccination and require 2 doses
I was born after 1970 with no laboratory evidence of measles immunity and require 2 doses
I was born after 1970 with documentation of only one dose of measles vaccine and requires a single dose
12
Medical History* This field is required.Please check all that applies to you
No Medical Conditions
Kidney, liver or spleen disorder
Immunocompromised (history of cancer, organ transplant, HIV infection, aplastic anemia, etc.)
Taking any immunosuppressants medications or treatment (chemotherapy, radiation, oral steroids, biological injections, etc.)
Autoimmune disease (Inflammatory bowel disease, lupus, rheumatoid arthritis, etc.)
Pregnant/breastfeeding or planned pregnancy within next 3 months
Myasthenia Gravis
Active neurological condition
History of Guillan-Barre Syndrome
Recent or planned Tb skin test
Allergies to: eggs, latex, neomycin, gelatin or thimerosal
Fainted or had a serious reaction to any vaccine(s)
Received blood products in the last 3 months
Other
13
Please Specify Medical Condition(s)Please expand on the Medical Condition(s)
E.g: Medical history, medical status, medications, etc.
14
Allergies* This field is required.Please specify the severity of the allergic reaction.
Please write “No Known Allergies” if no allergies
15
List any prescription(s) or over-the-counter medication(s) you are taking:* This field is required.
Please write “none” if you are not taking any prescription or over-the-counter medications
16
Are you experiencing any cold, flu or COVID-19-like symptoms, even mild ones? Symptoms include: fever, chills,
YESNO
17
Do you have a fever, infection or feel unwell?
YESNO
18
How did you hear about Pharmasave Lonsdale?* This field is required.
Online
Social Media
Family or Friends
Travel Agent
Doctor
Employer
Pharmacy
Other
19
Which search engine or website?e.g. Google, Bing, etc.
20
Which Social Media platform?e.g. Facebook, Instagram, LinkedIn, etc.
21
Name of family member or friend?
22
Which Travel agency?
23
Name of Doctor?
24
Name of Company?
25
Name of Pharmacy?
26
Please specify
27
Comment or Message
28
I confirm that I have provided all my health information on this form to the best of my knowledge.

I authorize the Healthcare Provider at Pharmasave Northwoods Village (Northwoods Village Pharmacy Ltd.) to administer vaccine(s) intramuscuarly or subcutaneously.

I agree to remain in the pharmacy/clinic for at least 15 minutes following vaccination(s).

I authorize the Healthcare Provider at Pharmasave Northwoods Village to administer epinephrine and/or life-saving procedures in the event of a severe allergic reaction.

I authorize Pharmasave Northwoods Village to contact me about a follow-up dose if required.

Due to a very rare possibility of an allergic or other reaction (about 1 for every one million vaccinations), please remain in the pharmacy for monitoring for at least 15 minutes after your vaccination.
29
Signature* This field is required.By signing below, I hereby attest that I confirm and agree to the information in this form. I attest the information provided is true and correct to the best of my knowledge and I give consent to the Healthcare Provider at Pharmasave Northwoods Village (Northwoods Village Pharmacy Ltd.) to administer the vaccine(s). I release the administering healthcare professional, the facility, the parent company, and any affiliated organizations from all liability arising from or related to the vaccine(s) or the operations supporting it.
Clear
Should be Empty: