COVID-19 Vaccine Consent Form for Adult
Open Youth form for those who are (5-17) age group
Message from the pharmacy:
We offer Pfizer and Moderna vaccine
Patient Information
The fields with a * are mandatory
First name
*
Last name
*
Gender
*
DOB
*
Email Address
*
Healthcard Number
Do not have a healthcard number
Address
City
Postal Code
Province
ON (Ontario)
Indigenous Identity
Other Indigenous Identity
Primary Care Provider
Mobile Number
Phone Number
Dosage History (Optional)
This section is optional but it is helpful to have it filled out
First Dose Date
First Dose Name
Second Dose Date
Second Dose Name
Third Dose Date
Third Dose Name
Fourth Dose Date
Fourth Dose Name
Consent to Receive Vaccine
Link to Consent to Receive Vaccine
/on/consents/adult/vaccine
I have read the above link and I consent to receiving the vaccine, including all recommended doses in the series.
Acknowledgement of Collection, Use and Disclosure of Personal Health Information
Link to Acknowledgement of Collection, Use and Disclosure of Personal Health Information
/on/consents/adult/acknowledgement
I have read the above link and understood it.
Link to Acknowledgement of Collection, Use and Disclosure of Personal Health Information - Follow Up
/on/consents/adult/acknowledgement_followup
I consent to receiving follow-up communications.
By Email
By SMS
Signature and Confirmation
Check here to indicate that you have read and agree to all the terms and references made in this online form
Date of Signature
*
If signing for someone other than myself, I confirm that I am the parent / legal guardian or substitute decision maker.
Relationship
Relationship to that other person (if above is checked):
Submit