COVID-19 Vaccine Screening and Consent

For children and youth under 18
Filling this out for an adult? Use the adult 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

Name of School

School Status

Primary Care Provider

Mobile Number

Parent / Legal Guardian Phone Number

Emergency contact name

Emergency contact relationship

Emergency contact phone number