COVID-19 VACCINATION 2021 CONSENT AND SCREENING FORM
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Email *
Last Name *
First Name *
Healthcard number /Identification *
Birthday *
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Phone number *
Street Address *
City *
Province *
Postal code *
Have you had your first COVID 19 Vaccine ? Yes or No *
If you’re booking for your second dose, what vaccine was administered as your first dose ?
When did you get your first dose ? ( MM/DD/YYYY)
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Are you 18 years old or above ? *
Family Doctor
Have you had a serious allergic reaction or any reaction within 4 hours of getting the COVID-19 Vaccine? *
Do you have allergies to polyethylene glycol, tromethamine or polysorbate ? *
Have you had a serious allergic reaction to a vaccine or medication given by an injection (eg. IV, IM) which required medical care? *
Have you had a vaccine in the past 14 days ? *
Are you/could you be pregnant or breastfeeding ?
CONSENT TO RECEIVING THE VACCINE BY PATIENT /AGENT I have read (or it has been read to me) and I understand the Immunization Prepackage including the following documents ‘Covid-19 Vaccine information sheet’ and ‘What you need to know about your Covid Vaccine Appointment’. I had the opportunity to ask questions regarding the vaccine I am receiving and to have them answered to my satisfaction. I understand that I may withdraw this consent at any time. I understand that if I am withdrawing consent as a substitute decision maker of an individual, then I must contact the congregate setting that the individual resides in . I agree to remain in the waiting area of the pharmacy for a minimum of 15 minutes after getting the Covid-19 vaccination. This is so that I may be observed for the rare occurrence of anaphylactic reaction. *
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SIGNATURE . Type your full name *
Date ( MM/DD/YYYY) *
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CONSENT ABOUT BEING CONTACTED ABOUT RESEARCH STUDIES You have the option of consenting to be contacted by researchers about participation in COVID19 vaccine related research studies. If you consent to being contacted, your personal health information will be used to determine which studies may be relevant to you, and your name and contact information will be disclosed to researchers. Consenting to be contacted about research studies does not impact your eligibility to receive the COVID-19 vaccine. If you do not wish to be contacted about research studies, please indicate this below. If you consent to be contacted about research studies and then change your mind, you may withdraw consent at any time by contacting the Ministry of Health at vaccine@ontario.ca. This will not impact your eligibility to receive the Covid-19 vaccine. I consent to be contacted about Covid-19 vaccine related research studies. *
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SIGNATURE .PLEASE TYPE YOUR FULL NAME *
SIGNATURE. PRINT LEGAL GUARDIAN OF PERSON PROVIDING CONSENT
SELECT A DATE
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ACKNOWLEDGEMENT OF COLLECTION,USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION The personal health information on this form is being collected for the purpose of providing care to you ,and because it is necessary for the administration of Ontario's Covid-19 vaccination program. This information will be used and disclosed for these purposes, as well as other purposes authorized and required by law. For example, it will be disclosed to the Chief Medical Officer of Health and Ontario Public Health units where the disclosure is necessary for a purpose of the Health Protection and Promotion Act . It may be disclosed, as a part of your provincial electronic record, to help providers who are providing care to you. The information will be stored in the health record system under the custody and control of the Ministry of Health. Where a clinic site is administered by a hospital, the hospital will collect, use and disclose your information as an agent of the Ministry of Health. *
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