COVID VACCINATION REGISTRATION
Enter information below to request an appointment at Northumberland Family Health Team for a COVID-19 vaccine. We are only booking appointments when we have received vaccine. We will post on nfht.ca/covidvaccine when we have clinic dates open. Please be assured we have received your response if you click submit. Please do not call in so our phone lines remain available for virtual care of our other patients.

COVID-19 Vaccines are offered by appointment only.
Email *
Last name *
First name *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Health Card Number (##########)
Enter with no spaces, no hyphens and no letters, please do NOT add the version code.
Phone number *
Enter in this format ### - ### - #### with hyphens please.
Family doctor first and last name.
Is this a request for a second shot of a Covid vaccination? If yes, please type here what did you receive for a first shot and when?
Have you received a vaccine of any kind in the last two weeks? Please type yes or no below. If yes, what did you receive, and when? *
If you are registering a youth between the ages of 12 and 17, please provide the name of their school or list homeschooled.
A copy of your responses will be emailed to the address you provided.
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