I have read (or it has been read to me) and I understand the Immunization Prepackage, including the following documents: ‘COVID-19 Vaccine Information Sheet’ or the ‘COVID-19 Vaccine Information Sheet: For Children (age 5-11)’ and What you need to know about your Covid-19 vaccine appointment. I have had the opportunity to ask questions regarding the vaccine and to have them answered to my satisfaction. I understand that I may withdraw this consent at any time.

Note: Please contact the vaccination clinic if you no longer consent to receiving the vaccine. If consent has been withdrawn by a substitute decision maker of an individual who resides in a congregate setting, then the congregate setting must contact the local public health unit