COVID-19 Vaccine Screening and Consent

For adults 18 and older
Filling this out for someone under 18? Use the youth form

Patient Info

Screening Questions

Consent

Patient Information

The fields with a * are mandatory

First name (as on health card) *

Last name (as on health card) *

Sex *

Date of birth *

Email Address *

Health Card Number

Do not have a health card number

Address

City

Postal Code

Province

ON (Ontario)

Indigenous Identity

Other Indigenous Identity

Primary Care Provider

Mobile Number

Phone Number

Emergency contact name

Emergency contact relationship

Emergency contact phone number