COVID-19 Vaccine Consent Form for Adult

Message from the pharmacy: GET YOUR COVID VACCINE HERE

Patient Information

The fields with a * are mandatory
ON (Ontario)
Mobile Number
Phone Number
Dosage History (Optional)

This section is optional but it is helpful to have it filled out
Consent to Receive Vaccine

/on/consents/adult/vaccine
Acknowledgement of Collection, Use and Disclosure of Personal Health Information

Signature and Confirmation

Relationship to that other person (if above is checked):