COVID-19 Vaccine Children / Youth (Age 5-17) Consent Form

Message from the pharmacy: COVID vaccine available here

Patient Information

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

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

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

Signature and Confirmation

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