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’ and ‘What you need to know about your Covid-19 vaccine appointment’.

• I have had the opportunity to ask questions regarding the vaccine I am receiving and to have them answered to my satisfaction.
• I understand that I may withdraw this consent at any time.
• I understand that if I am withdrawing consent as a substitute decision maker of an individual, then I must contact the congregate setting that the individual resides in.
• Note: Please contact the vaccination clinic where you are supposed to receive the Covid-19 vaccine if you change your mind and no longer consent to receiving the vaccine. This will allow someone else to take your spot. If consent has been withdrawn by a substitute decision maker of an individual who resides in a congregate setting, then the congregate setting must contact the local public health unit.