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

Open Adult form for those who are 17+

Message from the pharmacy: Get your Covid vaccines & ask us if you are up-to-date with your other vaccines!

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

Name of School

School Status

Indigenous Identity

Other Indigenous Identity

Primary Care Provider

Mobile Number

Parent / Legal Guardian 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/youth/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/youth/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/youth/acknowledgement_followup

I consent to receiving follow-up communications.

By EmailBy 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):